Ji  N*WU 


A  CLINICAL  ATLAS 


VARIATIONS 

OF   THE   BONES   OF 

THE  HANDS  AND   FEET 


BY 


THOMAS    DWIGHT,  M.D.,  LL.D. 

PARKMAN    PROFESSOR    OF    ANATOMY    AT    THE    HARVARD    MEDICAL    SCHOOL 


PHILADELPHIA  fcf  LONDON 

T.   B.   LIPPINCOTT    COMPANY 

nt>7 


Copyright,  1907 

BY 

J.  B.   Lippincott  Company 


Electrotyped  and  Printed  by  J.  B.  Lippincott  Company 
The  Washington  Square  Press,  Philadelphia,  U.  S.  .1. 


WE 


PREFACE 


The  constantly  increasing  use  of  the  X-ray  has  shown  that  the  study  of 
variations  is  not  a  scientific  fad  but  a  matter  of  very  great  practical  importance. 
Not  only  are  the  ordinary  variations  (still  but  little  known  to  the  surgeon)  con- 
stantly appearing,  but  very  uncommon  ones  are  occasionally  seen.  In  fact  the 
number  of  hands  and  feet  examined  by  the  X-ray  is  so  much  greater  than  that 
of  those  seen  post  mortem  by  anatomists,  that  it  is  not  surprising  that  varia- 
tions thought  excessively  rare  should  repeatedlv  be  brought  to  light. 

For  many  years  I  have  devoted  myself  to  the  study  of  variations  in  man, 
especially  to  those  of  the  spine  and  of  the  bones  of  the  hand  and  foot.  The 
importance  of  these  in  the  practice  of  surgery  becomes  clearer  day  by  day. 
This  Atlas  has  been  prepared  for  the  use  of  the  practitioner.  Some  variations 
are  discussed  which  are  of  interest  to  the  orthopaedist,  but  attention  has  been 
given  chiefly  to  those  which  may  be  expected  to  appear  in  skiagraphs  taken 
after  an  injury  and  which  may  suggest  a  fracture  to  the  unwary. 

As  the  work  is  meant  first  of  all  to  be  practical,  scientific  discussion  has  been 
0  reduced  to  a  minimum.  It  is  necessary,  however,  to  give  the  plan  of  the  hand 
and  foot  according  to  the  views  of  the  lamented  Professor  Pfitzner,  whose  name 
will  live  as  that  of  the  pioneer  in  this  line  of  research.  Although  I  do  not  accept 
his  theory  without  reserve,  and  disagree  with  him  on  some  points,  I  find  it  very 
useful  as  a  working  hypothesis. 

Every  single  bone  specimen  shown  in  these  photographs  was  observed  by 
me  and  belongs  to  the  Harvard  Medical  School.  Almost  all  of  them  are  in  the 
Warren  Museum.  I  wish  to  acknowledge  the  courtesy  of  the  authorities  of  the 
Journal  of  the  American  Medical  Association  and  of  the  Anatomischer  Anzeiger 
in  allowing  the  reappearance  of  illustrations  which  have  been  published  in  their 
pages. 

The  skiagraphs  were  taken  at  the  Massachusetts  General  Hospital.  I  have 
much  appreciated  the  hospitality  of  that  institution  by  which  I  have  been  able 
to  examine  many  hundred  negatives  and  to  publish  such  as  I  wished.  I  cannot 
express  too  strongly  my  indebtedness  to  Mr.  Walter  J.  Dodd,  the  head  of  the 
X-ray  department,  for  his  unfailing  patience,  his  valuable  help  and  constant 
<v9  interest. 


Thomas  Dwight. 


Harvard   Medical   School,  October,  1907. 


577933 


ILLUSTRATIONS 

LIST  OF  FIGURES  OF  HAXDS. 

I.     i.  X-ray  of  triangulare. 

2.  Divided  scaphoid. 

3.  Divided  scaphoid.     Fracture  (?)  centrale. 

II.     4.  Fracture  of  radius,  divided  scaphoid.     X-ray. 
5.  Possible  fracture  of  scaphoid.     X-ray. 

III.  6.  X-ray  of  several  scaphoids  in  pronation. 

7.  Different  shapes  of  scaphoid,  some  showing  centrale. 

8.  Two  drawings  of  scaphoid  of  fig.  2. 

9.  X-ray  of  the  same. 

10.  Sections  of  two  scaphoids  showing  internal  structure. 

IV.  11.  X-ray  of  centrale. 

12.  X-ray  showing  hole  for  centrale. 

V.   13.  Radiale  externum. 

14.  Epilunatum  free. 

VI.   15.  Divided  semilunar. 

16.  Two  semilunars  with  fused  epilunatum  and  one  with  cavity. 

17.  Ulnare  externum,  epilunatum  fused  with  semilunar. 
VII.   18.  Secondary  pisiform  probably  lost. 

19.  Pisiform  with  fused  secondary  pisiform. 

20.  Praetrapezium. 
VIII.   21.  Subcapitatum. 

22.  Separate  hamular  process. 

23.  Variously  developed  hamular  processes. 
IX.   24.  Separate  styloid. 

25.  Separate  styloid.      X-ray. 
X.   26.  Styloid  fused  with  trapezoid. 
27.  Styloid  fused  with  os  magnum. 
XI.   28.  Fusion  of  cuneiform  and  semilunar.      Dorsal  view.       Large  normal  styloid. 
29.  Similar  condition,  palmar  view. 
XII.  30.  Proximal  epiphysis  of  second  rnetacarpal.     X-ray. 
31.  Fusion  of  trapezoid  with  second  metacarpal. 

XIII.  32.  Fusion  of  fourth  and  fifth  metacarpals.     X-ray. 
33.  Ditto  in  bone. 

LIST  OF  FIGURES  OF  FEET. 

XIV.  34.  Trigonum,  left  single,  right  double. 
XV.  35.  Trigonum  at  end  of  long  process. 

36.  Trigonum,  side  view.      Fusion  of  second  and  third  phalanges  of  little  toe. 
Synchondrosis  of  os  calcis  and  scaphoid. 

v 


XIX. 

44- 

XX. 

45- 

46. 

47- 

XXI. 

48. 

49- 

XXII. 

50. 

XXIII. 

S1- 

S2- 

XXIV. 

S3- 

54- 

XXV. 

55- 

56. 

vi  ILLUSTRATIONS 

LIST  OF  FIGURES  OF  FEET  (Continued). 

XVI.   37.   X-iay  of  trigonum. 

38.  Left  trigonum  almost  free,  right  almost  fused. 
XVII.  3Q.  Large  internal  process  of  astragalus. 
40.  Trochlear  process  near  head. 
XVIII.  41.  Variation  of  angle  of  inclination  of  head  of  astragalus. 

42.  Variation  of  lateral  inclination  of  neck. 

43.  Varying  development  of  external  process. 
Immense  peroneal  process  like  chimpanzee.      Tibiale  externum  fused. 
Large  peroneal  process.     Pathological. 

46.  Varying  inclination  of  calcaneum  and  development  of  plantar  tubercles. 
The  latter  point  shown  on  the  plantar  surface. 

Synchondrosis  of  calcaneum  and  scaphoid.      Good  peroneal  process. 
X-ray  of  above  condition. 
Secondary  calcaneum  in  both  feet.     X-ray. 
Secondary  calcaneum. 
Tibiale  externum. 
Tibiale  externum. 

Ditto.      Fused  as  a  hook  to  scaphoid. 
X-ray  of  tibiale  externum  of  kind  in  fig.  53. 
Ditto  of  kind  in  fig.  54. 
XXVI.   57.  Secondary  cuboid  fused  with  scaphoid. 
58.   Ditto.     Another  foot,  seen  from  side. 
XXVII.   59.  Secondary  cuboid  fused  with  scaphoid  and  variously  developed. 
60.  Various  development  of  tibiale  externum  fused  with  scaphoid. 
XXVIII.  61.  Skiagraph  of  divided  cuneiform. 

62.  Same  from  side;  also  tibiale  externum. 
XXIX.  63.   Intercuneiform. 

64.  Intercuneiform  and  secondary  calcaneum. 
XXX.   65.   Synchondrosis   of  scaphoid  and  cuboid  with   perhaps  secondary   cuboid 
fused  with  scaphoid. 
66.   Well-developed  peroneum.      X-ray. 
XXXI.   67.  Very  large  peroneum. 

68.  X-ray  previously  made  from  same  foot. 
XXXI  1 .   69.   Intermetatarseum  free  on  both  sides. 

XXXIII.  70.  Intermetatarseum  fused  with   internal    cuneiform.      Secondary  os  calcis 
and  tibiale  externum. 

71.   Ditto.     Fused  with  second  metatarsal. 

XXXIV.  72.  Ditto.      Fused  with  first  metatarsal. 
73.  Fusion  of  external  cuneiform  and  third  metatarsal. 

XXXV.   74.  Varying  development  of  tuberosity  of  fifth  metatarsal. 

75.  X-ray  of  Ve.salianum. 

XXXVI     76.  Internal  sesamoid  of  the  great  toe  divided.     X-rav. 

77.  Fusion  of  last  two  phalanges  of  little  toe. 

78.  X-ray,  suggestion  of  four  phalanges  in  little  toe. 

79.  Ditto. 


INTRODUCTION 


It  is  still  customary  to  teach  that  the  wrist  consists  of  eight  bones  and  the 
ankle  of  seven,  the  homologies  of  which  are  not  altogether  so  clear  as  could  be 
wished.  Nevertheless  it  is  well  known  that  at  an  early  stage  the  wrist  and  ankle 
of  the  human  embryo  contain  many  centres  indicating  bones  which  during 
development  either  disappear  utterly  or  fuse  with  others,  of  which  they  form 
more  or  less  important  parts.  Thus,  though  usually  undistinguishable,  they 
may  exceptionally  persist  either  as  isolated  (supernumerary)  bones,  or  as  very 
evident  processes  on  some  of  the  permanent  elements.  The  arrangement  of 
these  centres  in  the  praseartilaginous  stage  is  supposed  to  be  on  a  flipper-like 
plan  after  the  fashion  of  the  ancient  saurians.  Some  centres  are  easily  identified 
as  representing  elements  familiar  to  the  student  of  comparative  anatomy ; 
others  are  of  uncertain  significance.  Let  us  now  follow  a  little  more  in  detail 
what  actually  occurs  in  the  human  wrist.  The  cells  of  the  undifferentiated 
tissue  arrange  themselves  in  groups  which  represent  possible  bones.  Histological 
changes  occur  by  which  certain  of  these  groups  become  cartilaginous  centres. 
Not  all  of  them,  however,  go  so  far.  Some  lose  their  identity  very  soon.  Others, 
having  become  cartilaginous,  may  disappear,  leaving  no  trace  behind  them,  or 
they  may  join  themselves  to  other  centres,  thus  forming  a  composite  bone.  On 
the  other  hand,  they  may  pursue  an  exceptional  course  and  persist  as  separate 
bones.  But  to  return  to  the  story  of  development:  after  these  centres,  or  some 
of  them,  have  become  cartilaginous,  the  tissue  between  them  breaks  down  so  as 
to  form  the  synovial  cavities  between  the  bones,  while  in  other  places  fibrous 
tissue  appears,  forming  ligaments,  or  so-called  fibro-cartilage,  connecting  them. 
It  is  to  be  noted  that  some  of  these  centres  are  found  in  perhaps  79  per  cent,  of 
the  embryonic  hands.  Now,  as  to  the  fate  of  a  group  of  cells  of  the  cartilaginous 
era  which,  instead  of  disappearing  as  usual,  for  some  reason  or  other  preserves  its 
individuality  more  or  less  perfectly.  It  may  become  an  absolutely  free  bone. 
Such  a  one  may  be  connected  with  its  neighbours  by  true  joints  on  one  or  more 
surfaces,  or  it  may  have  merely  a  ligamentous  attachment.  It  may  become 
closely  connected  with  one  or  more  of  its  neighbours  by  fibro-cartilage  and 
present  the  characteristic  surface  that  is  found  on  bones  so  connected.  Again 
it  may  be  actually  fused  with  a  neighbour  but  so  clearly  marked  off  on  the 
surface  that  there  is  no  question  as  to  its  identity;  and  finally  it  may  be  so 
intimatelv  fused  and  so  shorn  of  its  own  characteristics  as  to  leave  its  nature 


viii  INTRODUCTION 

very  problematical.  It  is,  moreover,  to  be  noted  that  one  of  these  exceptional 
elements  may  be  connected  in  these  various  degrees  of  intimacy  with  no  partic- 
ular bone  but  with  any  one  of  its  neighbours,  thereby  very  considerably  modify- 
ing their  shape.  As  an  illustration  take  what  is  commonly  known  as  the  styloid 
process  of  the  third  metacarpal.  It  is  found  as  a  separate  element  in  a  large 
proportion  of  embryos.  It  may  persist  as  a  separate  bone  throughout  life,  with 
synovial  surfaces;  or  it  may,  as  is  usually  the  case,  fuse  with  the  third  metacar- 
pal, forming  the  so-called  styloid  process.  It  may,  however,  join  the  os  magnum, 
and  more  rarely  the  trapezoid.  Finally,  and  this  is  important,  while  joining 
one  bone,  let  us  say  the  metacarpal,  by  true  bony  union,  the  surface  towards  the 
os  magnum,  instead  of  the  articular  covering  which  is  usual,  may  be  connected 
to  that  bone  wholly  or  in  part  by  fibrous  cartilage.  This  union  may  indeed  be 
so  close  that  before  maceration  the  bones  may  be  thought  to  be  continuous. 
In  fact,  fusion  with  both  bones  may  occur.  Moreover,  such  an  element,  before 
fusing  with  another  bone,  may  wander  a  little  from  its  original  position. 

Sesamoid  bones  deserve  in  this  connection  very  particular  mention.  In  the 
first  place,  a  sesamoid  bone  under  normal  circumstances  is  laid  down  in  carti- 
lage as  distinctly  as  any  other  bone  and  deserves  to  be  considered  a  regular 
and  typical  part  of  the  skeleton.  Bones  sometimes  called  sesamoids  are 
beyond  question  bones  to  be  considered  as  typical  parts  of  the  wrist  and 
ankle,  as,  for  instance,  the  tibiale  externum  of  comparative  anatomy,  but  more 
commonly  known  among  us  as  the  sesamoid  in  the  tendon  of  the  tibialis 
posticus.  We  shall  see  later  that  it  is  occasionally  fused  or  closely  united 
to  the  scaphoid.  What  is  a  bone  of  the  skeleton  in  certain  animals  may  be 
merely  a  swelling  in  a  tendon  in  others,  apparently  represented  in  some  cases 
merely  by  an  accumulation  of  fibrous  tissue;  or  again  it  may  be  a  well-developed 
bone.  The  sesamoids  of  the  metacarpo-phalangeal  joints  and  those  of  the 
interphalangeal  joints  and  the  corresponding  ones  in  the  foot  are  much  more 
numerous  in  the  foetus  than  in  the  adult.  In  some  carnivora  and  other  animals 
there  are  also  dorsal  sesamoids  of  which  but  very  few  representatives  have  been 
found  in  the  human  being.    At  least  most  sesamoids  have  no  particular  function. 

It  is  evident  from  what  has  been  said  that  the  first  class  of  variations  is  due  to 
the  persistence  of  elements  apparently  having  a  place  in  the  plan  of  the  wrist 
and  ankle  which  usually  disappear,  thereby,  if  free,  increasing  the  number  of 
bones.  Xow,  in  the  second  class  the  converse  occurs.  There  may  be  too  few  bones, 
from  the  union  of  pieces  usually  distinct.  It  has  been  said  that,  in  the  early 
cartilaginous  stage  when  the  joint  cavities  appear,  fibrous  tissue  is  developed 
at  certain  places.  It  is  easy  to  conceive  that  instead  of  this  coming  to  pass  two 
future  bones  may  be  connected  by  cartilage  which  later  turns  into  bone.  The 
articular  cavity  may  not  appear  or  cartilage  may  develop  instead  of  fibrous 


INTRODUCTION  ix 

tissue.  Still  another  cause  is  assigned  by  Pfitzner, — namely,  that  an  occasional 
bone  which  usually  does  not  appear,  or  at  most  is  represented  bv  a  tubercle  on 
another  bone,  may  be  connected  either  by  bony  tissue  or  by  fibro-cartilage 
with  two  neighbouring  bones  which  it  thus  unites.  I  see  no  difficulty  in  accept- 
ing all  these  explanations.  There  is  a  third  class  of  variations  absolutely  dif- 
ferent, in  theory  at  least,  from  those  already  mentioned.  It  includes  cases  of 
large  processes  in  places  where  there  is  normally  either  a  small  one  or  none  at 
all.  Among  these  are  some  which  may  reasonably  be  considered  pathological 
or  at  least  regarded  with  suspicion,  but  which  nevertheless  are  found  at  certain 
definite  places  and  present  tolerably  constant  features.  Be  the  explanation 
what  it  may,  these  deserve  to  be  recognized.  Finally,  it  might  be  said  that  there 
is  a  fourth  class  of  variations,  consisting  in  departure  from  the  ordinary  relations 
of  bones.  This  can  be  called  a  class  only  because  this  difference  of  relation  is 
the  feature  on  which  we  fix  our  attention.  It  is  true  that  this  may  be  of  great 
practical  significance,  but  it  is  clear  that  this  difference  of  relation  (putting 
aside  cases  in  which  one  bone  is  exceptionally  large  or  small)  must  depend  on 
some  of  the  foregoing  causes  and  is  really  the  result  of  a  variation  of  one  of  the 
three  true  classes. 

For  the  understanding  of  the  occasional  bones  it  is  necessary  to  give  Pfitzner's 
plan  of  the  hand  and  foot.  These  are  considered  separately  and  no  attempt  is 
made  to  discuss  the  homologies  of  the  limbs.  Both  hand  and  foot,  however, 
consist  theoretically  of  a  number  of  longitudinal  rays  (the  question  whether 
there  be  five  or  seven  need  not  be  opened),  the  elements  of  which  are  also  ar- 
ranged in  transverse  rows.  Pfitzner  indeed  seems  to  think  that  the  longitudinal 
arrangement  is  interrupted  at  the  wrist,  but  this  also  we  pass  over.  While  I 
think  that  Pfitzner's1  theory  should  be  adopted  as  a  working  hypothesis,  there 
is  one  objection  to  it.  In  his  discussion  of  certain  doubtful  elements  in  his  work 
he  points  out  that  element  .4,  for  instance,  cannot  be  element  B  because  the 
latter  is  clearly  present.  Now,  in  point  of  fact,  I  think  that  I  have  several  times 
seen  the  same  element  represented  by  two  swellings  on  adjacent  bones  in  the 

1  Pfitzner  occupies  a  rank  by  himself  among  students  of  variations  of  hands  and  feet. 
I  shall  have  to  refer  to  him  constantly.  To  avoid  endless  repetition  I  give  here  the  references 
once   for   all. 

I.  Beitrdge  zur  Kenntniss  des  menschlichen  Exiremiidtenskelets.  SchwaJbe's  Morpho- 
logische  Arbciten,  Band  i,  1892.  This  paper  deals  with  general  principles  and  certain  meas- 
urements, which  latter  are  not  discussed  in  this  work. 

II.  Die  Sesambeine  des  menschlichen  Kdrpers.     Ditto.     Devoted  entirely  to  sesamoids. 

III.  Die  Variaiion  in  Aufbau  des  Handskelcts.  Ditto,  Band  iv,  1895.  This  is  a  very 
thorough  discussion  of  the  variations  of  the  hand. 

IV.  Die  Variation  in  Aufbau  des  Fusskelets.  Ditto,  Bandvi,  iSq6.  A  very  thorough  discus- 
sion of  the  variations  of  the  foot.    Consult  the  sections  on  the  individual  bones  in  this  paper. 


x  INTRODUCTION 

same  wrist.  The  error  consists  in  holding  that  a  certain  permanent  condition 
must  always  be  brought  about  by  the  same  element.  Now.  studies  in  variation 
show  clearlv  that  when  there  is  an  initial  error  or  deviation  in  the  course  of 
development  there  is  an  effort  in  the  organism  to  reproduce  the  normal  condi- 
tion as  nearly  as  circumstances  will  permit,  and  this  may  be  accomplished  by 
changes  in  other  parts. 

Pfitzner  has  received  most  valuable  support  from  the  embryological  work  of 
Thilenius,1  who  looked  for  elements  in  the  earlier  embryonic  carpus  and  has 
shown  that  those  which  appear  very  rarely  in  the  adult  may  be  found  with  great 
regularity  in  the  first  stages  of  development.  His  nomenclature  and  plan  of 
the  carpus  are  not  quite  the  same  as  Pfitzner's. 


V.  and  VI.  Die  morphologischcn  Elemente  des  menschlichcn  Handskelets.  AUgemeiner 
Theil,  Zeitschrifi  j/ir  Morphologic  und  Anthropologic,  Band  ii,  1900,  S.  77.  Specieller  Theil, . 
ditto,  S.  365.  In  the  former  of  these  papers  there  is  a  general  discussion  of  the  question  as 
applied  to  the  hand.  On  page  152  a  list  of  the  elements  which  he  recognizes  is  begun;  on 
pages  156  and  157  are  the  diagrams  of  the  carpus  according  to  his  ideas.  These  diagrams 
supersede  those  of  a  previous  paper. 

In  the  special  part  he  gives  a  description  of  1456  hands  and  goes  through  the  variations 
again.  Thus,  in  referring  to  any  particular  variation  of  the  hand  it  is  best  to  look  it  up  in 
this  article,  and  if  necessary  refer  back  to  the  former  one  of  1895.  In  this  paper  he  gives 
also  a  description  of  the  normal  bones. 

1  The  following  papers  by  Thilenius  should  be  studied  by  those  interested  in  the 
scientific  side  of  the  question. 

Zur  Eu.icickclungsgcschicli.c  der  Scsambeinc  dcr  menschlichcn  Hand.  Schwalbc's  Morph. 
Arbeitcn,  Hand  v,  189^. 

U  titer suchungen  Other  die  Morphologische  Bedeutung  accessorischer  Elemente  am  mensch- 
lichcn Carpus.   Morph.  Arbeit.,    Band  v. 

Accessorische  und  cchte  Skcletsiucke.  Anat.  Anzciger,  Band  xiii. 


VARIATIONS 

OF  THE  BONES  OF 

THE  HANDS  AND  FEET 


THE  HAND. 


Pfitzner's  plan  of  the  hand  is  as  follows:  First,  an  antibrachial  row- 
composed  of  two  bones  very  rarely  met  with  in  the  adult,  the  triangulare  and 
the  secondary  pisiform.  Second,  the  proximal  row,  consisting  of  the  radial  and 
ulnar  scaphoids,  which  normally  form  the  greater  part  of  the  scaphoid,  the 
semilunar,  the  radial  and  the  ulnar  cuneiform,  which,  however,  have  never  been 
seen  separate,  and  the  pisiform;  the  central  row  consisting  of  several  elements 
none  of  which  normally  persists  as  a  separate  bone;  they  are  the  radiate  ex- 
ternum joining  the  outer  side  of  the  tuberosity  of  the  scaphoid,  the  epitrape- 
zium  a  very  rare  and  unimportant  little  ossicle  on  the  dorsum  of  the  trapezium, 
the  centrale  which  Pfitzner  divides  into  a  dorsal  and  a  palmar  element,  the  latter 
of  which  may  be  left  out  of  practical  consideration,  the  epilunatum  which  nor- 
mally forms  the  tip  of  the  dorsal  point  of  the  semilunar,  the  hypolunatum  in  a 
corresponding  relation  to  the  palmar  point,  the  epipyramis  forming  the  radial 
angle  on  the  dorsal  surface  of  the  cuneiform,  and  the  ulnare  externum  on  the 
dorsal  aspect  of  the  cuneiform  at  the  edge  of  the  hand  near  or  against  the 
unciform.  The  distal  row  contains  the  trapezium,  the  trapezoid,  or  rather  its 
palmar  half,  the  metastyloid  a  small  ossicle  at  the  tip  of  the  styloid  of  the  third 
metacarpal  between  the  trapezoid  and  the  os  magnum,  the  capitatum  proprium 
which  forms  the  proximal  and  the  chief  part  of  the  os  magnum,  and  the  unciform. 
The  carpo-metacarpal  row  consists  of  a  number  of  bones  none  of  which  is  seen 
in  a  normal  hand;  the  paratrapezium  constituting  the  outer  angle  of  the  tra- 
pezium, the  prcetrapezium  on  the  palmar  aspect  of  the  tuberosity  of  the  tra- 
pezium, the  trapezium  secundarium,  the  ulnar  distal  angle  of  the  trapezium, 
the  secondary  trapezoid  on  the  dorsum  between  trapezoid,  trapezium  and  second 
metacarpal,  the  epitrapezoid  which  is  essentially  the  greater  part  of  the  dorsum 
of  the  trapezoid,  the  parastyloid  forming  the  dorsal  ulnar  projection  of  the  base 

1 


2        VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

of  the  second  metacarpal,  the  styloid  being  the  element  which  usually  forms 
the  stvloid  process  of  the  third  metacarpal,  the  subcapitatum  forming  the  swell- 
ing in  the  palm  on  the  distal  half  of  the  os  magnum,  the  capitatum  secundarium 
forming  the  dorsal  distal  portion  on  the  ulnar  side  of  the  os  magnum,  Gruber's 
ossicle  a  small  element  in  the  palm  at  the  point  of  junction  of  the  lines  sepa- 
rating the  third  and  fourth  metacarpals  and  the  os  magnum  and  unciform, 
the  os  hamuli  which  is  the  unciform  process  of  the  bone  of  that  name,  the  bone 
of  Vesalius  or  Vesalianum,  forming  the  tip  of  the  tuberosity  of  the  fifth  meta- 
carpal. 

VARIATIONS  AND  ADDITIONAL  BONES. 

It  is  proposed  in  discussing  the  yariations  of  the  hand  and  foot  to  take  the 
normal  bones  in  order  and  to  describe  the  occasional  bones  at  the  same  time  as 
the  normal  elements  with  which  they  are  most  intimately  associated.  Thus 
the  styloid,  which  belongs  in  the  carpo-metacarpal  row,  shall  be  considered  w7ith 
the  third  metacarpal  of  which  it  is  normally  the  styloid  process,  and  the  radi- 
ate extern n in,  instead  of  being  considered  with  the  central  row,  none  of  the  ele- 
ments of  which  normally  appears  as  a  separate  bone,  shall  be  treated  of  with 
the  scaphoid  of  which  it  forms  the  extreme  radial  projection.  This  course  will 
make  the  matter  more  simple.  One  of  the  bones  of  the  antibrachial  row,  the 
triangulare,  must,  however,  be  taken  by  itself. 

The  triangulare  is  very  common  in  the  early  embryo,  having  been  found 
by  Thilenius  '  in  65  per  cent,  in  the  second  month;  but  it  is  very  rare  in  the 
adult.  It  is  situated  theoretically  between  the  radius  and  ulna  on  one  side  and 
the  semilunar  and  cuneiform  on  the  other,  on  the  distal  surface  of  the  so-called 
triangular  cartilage,  which  according  to  Pfitzner2  is  really  nothing  but  fibrous 
tissue.  I  have  seen  a  minute  ossification  in  this  situation  in  several  skia- 
graphs. I  have  once  seen  a  small  ossicle  projecting  from  the  distal  end  of  the 
heal  of  the  ulna  near  the  base  of  the  styloid  process  which  may  be  supposed 
to  be  this  element.  It  may  wander  towards  and  beyond  the  tip  of  the  styloid 
process  of  that  bone.  Pfitzner  figured  an  ulna  with  the  tip  of  the  styloid  separate 
from  the  rest.  In  figure  1  is  given  a  skiagraph  of  a  similar  occurrence,  though, 
as  is  stated  more  fully  in  the  description,  there  had  been  an  injury  of  the  hand. 
There  is  some  danger  of  confounding  the  triangulare  with  the  far  rarer  secondary 
pisiform,  of  which  later,  when  the  bone  is  near  the  tip  of  the  styloid  process  of 
the  ulna,  hut  the  practical  point  is  this, — namely,  that  a  small  ossicle  may  be 
found  on  (or  below)  the  distal  surface  of  the  triangular  cartilage,  and  also  beyond 
the  tip  of  the  styloid  process  of  the  ulna,  or  on  its  radial  side,  which  by  its  out- 


1  Schwalbe's  MorpHolog.  Arbeiten,  Bd.  v,  1896. 

2  Some  cartilage  cells  have  been  found  in  it. 


THE  HAND— VARIATIONS  AND  ADDITIONAL  BONES  3 

line  can  easily  be  distinguished  from  a  recent  fracture.  Among  uncommon  rela- 
tions of  the  bones  may  be  mentioned  a  single  case,  observed  by  Pfitzner,  of  the 
articulation  of  the  styloid  process  of  the  ulna  with  both  the  cuneiform  and  the 
pisiform,  after  the  fashion  commonly  found  in  mammals. 

The  scaphoid.  This  bone,  according  to  the  plan  we  are  following,  is  com- 
posed of  two  chief  parts,  a  radial  and  an  ulnar  scaphoid,  and  of  certain  accessory 
ones,  namely  a  radiale  externum  and  a  centrale.  The  epilunatum  moreover 
is  occasionally  fused  with  it.  The  scaphoid  presents  a  great  range  of  variations 
of  size  and  shape  as  well  as  of  internal  structure,  which  have  their  importance 
in  the  discussion  of  the  burning  question  of  subdivided  scaphoid.  There  is  little 
exaggeration  in  saying  that  before  the  X-ray  practically  nothing  had  been  heard 
of  fracture  of  the  scaphoid.  The  bone  is  first  laid  down  as  a  single  group  of  cells. 
Ossification  begins  very  late,  about  the  sixth  year,  apparently  usually  by  a 
single  centre,  though  two  have  been  described.  There  is  no  question,  however, 
that  the  bone  may  develop  in  two  nearly  equal  parts.  A  double  cartilaginous 
centre  has  been  seen  by  v.  Bardeleben.1  Thilenius2  has  found  in  an  embryo 
conclusive  signs  of  the  union  of  two  parts  having  already  occurred.  I  have  had 
the  fortune  to  find  the  bone  subdivided  at  birth.  There  are  cases  of  partial 
division  in  which  the  two  pieces  have  almost  lost  their  individuality  but  in  which 
the  concave  surface  shows  a  deep  cut  just  below  the  dorsum,  or  a  fine  fissure 
crossing  it.  The  latter  may  be  represented  by  a  line  of  nutrient  foramina. 
It  is  not  rare  to  find  a  large  cavity  near  the  middle  of  the  scaphoid  which  may 
be  both  the  consequence  of  an  early  subdivision  and  also  a  predisposition  to 
fracture. 

The  study  of  thin  sections  of  the  scaphoid  as  well  as  of  skiagraphs  shows 
very  great  differences  in  the  internal  structure  of  the  bone.  Often  the  sections 
show  a  denser  structure  at  the  proximal  end,  the  network  of  trabeculae  being 
of  what  I  have  called  the  round-meshed  pattern  such  as  is  found  in  the  head  of 
the  femur,  which  is  followed  by  a  distinctly  weaker  region  at  the  middle,  and 
by  a  denser  structure  chiefly  of  parallel  plates  at  the  distal  end.  This  latter 
denser  region  is  not  usually  as  dense  as  the  proximal  one.  X-ray  plates  show 
much  variation  and  are  often  difficult  to  interpret.  Sometimes  the  internal 
structure  consists  of  beautifully  distinct  trabecular  no  closer  together  at  one 
place  than  at  another,  while  again  the  greatest  density  is  in  the  distal  radial 
half.  Often  the  figure  is  crossed  bv  a  curved  line  with  its  convexity  to  the  ulnar 
side  probably  caused  bv  the  swelling  of  the  palmar  part  of  the  distal  end. 

In  a  considerable  proportion  of  scaphoids  there  are  signs  of  an  incom- 
plete division,  or,   more  accurately,  of  an  incomplete  union  of  two  originally 

1  Jenaische  Zeitschrift,  Bd    xix.  S.  149. 

2  Morpholog.  Arbeiten,  Bd.  v,  S.  475. 


4  VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

distinct  elements.  In  a  comparatively  small  number  of  adult  hands  the  sca- 
phoid is  found  completely  divided.  As  Pfitzner  has  shown,  the  line  of  division 
runs  obliquely  from  near  the  outer  end  of  the  articular  surface  for  the  radius 
to  about  the  middle  of  the  concavity  for  the  head  of  the  os  magnum.  Thus  the 
bone  is  divided  into  a  somewhat  larger  radial  element  distally  situated  and  bear- 
ing the  trapezium  and  trapezoid,  and  into  an  ulnar  element  placed  beside  the 
semilunar.  That  this  division  may  occur  without  fracture  is  absolutely  unde- 
niable. I  have  found  the  bone  in  two  pieces  in  the  right  hand  of  a  white  man  of 
sixtv-one.  The  same  hand  had  an  extra  bone  of  difficult  interpretation  (prob- 
ably an  epipyramis)  on  the  dorsal  aspect  of  the  cuneiform.  The  left  scaphoid 
was  in  one  piece,  and  there  was  a  free  epilunatum  in  that  hand.  The  two  pieces 
were  in  perfect  apposition,  and  the  bone  showed  no  sign  of  injury.  After  the 
bone  had  been  drawn  and  a  skiagraph  made  from  it,  I  had  it  cut  into  thin  slices 
which  showed  a  strip  of  cartilage  between  the  pieces.  An  expert  who  examined 
it  at  my  request  agreed  with  me  that  the  pieces  were  in  their  original  relations. 
Figure  4  is  a  skiagraph  of  a  fractured  radius.  The  erroneous  diagnosis  of  a 
fracture  of  the  scaphoid  had  probably  been  added  after  the  plate  had  been  made. 
One  has  only  to  compare  the  articular  surfaces  of  the  two  pieces  of  the  scaphoid 
with  those  of  other  bones  in  the  same  wrist,  and  to  contrast  their  appearance 
with  that  of  the  undoubted  fracture  of  the  radius  to  know  that  this  is  a  case  of 
subdivided  scaphoid.  In  some  specimens  the  surfaces  of  the  two  pieces  are  held 
together  by  degenerated  fibro-cartilage  or  articular  cartilage  which  had  been 
prettv  much  worn  away,  but  which  presented  a  very  different  appearance  from 
that  of  the  surface  of  a  fracture. 

It  must  be  frankly  admitted  that  the  great  majority  of  specimens  of  sub- 
divided scaphoid  have  a  very  pathological  appearance.  Pfitzner  is  very  nearly 
at  the  point  of  denying  the  occurrence  of  fracture  in  any  of  these  cases.  I  think 
this  is  going  too  far,  for  the  history  of  lesion  is  often  very  precise  and  I  do  not 
doubt  that  an  undivided  scaphoid  may  be  broken.  Pfitzner  argues  very  con- 
vincingly that  a  subdivided  scaphoid  is  not  a  good  mechanical  arrangement, 
that  the  pieces  playing  one  on  the  other  become  displaced,  that  the  cartilage 
degenerates,  the  surfaces  become  eburnated  and  finally  signs  of  inflammation 
appear  marked  by  the  formation  of  irregular  pieces  of  bone.  To  this  I  would 
add  that  a  subdivided  scaphoid  is  no  charm  against  the  accidents  to  which  all 
arc  liable.  On  the  contrary  it  makes  a  slight  injury  the  more  serious,  as  such  a 
hoid  may  be  lacerated  by  violence  which  would  not  have  broken  a  normal 
bone.  I  am  far  from  questioning  the  diagnosis  in  many  cases  of  fracture  of  the 
scaphoid.  I  do  not  deny  that  a  normal  bone  may  be  broken;  but  I  strongly 
suspeel  thai  in  most  cases  called  fractures  there  was  a  subdivided  bone  to  begin 
with.     There  are  some  very  pathological  specimens  in  which  the  bone  consists 


THE  HAND— VARIATIONS  AND  ADDITIONAL  BONES  5 

of  at  least  three  pieces.  Whether  these  are  due  to  pathological  causes  during 
development  or  to  degenerative  changes  probably  following  a  lesion  I  must 
leave  undetermined.1 

The  radiate  externum  (a  term  used  in  comparative  anatomy)  is  the  end  of 
the  tubercle  of  the  scaphoid.  I  have  seen  it  both  in  X-rays  and  in  specimens, 
but  I  have  always  found  either  a  history  of  lesion  with  the  former  or  signs  of 
inflammation  with  the  latter.  Pfitzner,  however,  figures  cases  which  show  noth- 
ing pathological.  Although  very  generally  found  among  mammals,  it  is  exces- 
sively rare  in  man. 

The  centrale,  which  it  is  convenient  to  consider  with  the  scaphoid,  is  almost 
constant  as  a  group  of  cells  in  the  early  embryo,  and  is  normal  as  high  in  the  scale 
as  the  ourang,  but  it  is  one  of  the  most  uncommon  bones  to  find  distinct  in  the 
adult.  For  all  practical  purposes  it  is  a  dorsal  element.  Its  usual  fate  is  to  fuse 
with  the  scaphoid,  but  it  may  disappear  completely  or  fuse  with  the  os  magnum, 
and  perhaps  with  the  trapezoid.  It  is  found  relatively  often  in  cases  of  sub- 
divided scaphoid.  When  it  disappears  completely,  its  place  being  taken  by 
fibrous  tissue,  skiagraphs  show  a  very  striking  void  between  the  os  magnum  and 
the  distal  part  of  the  scaphoid.  Sometimes  they  show  the  centrale  projecting 
into  this  space  from  the  latter  bone.  Sometimes  it  is  partially  marked  off 
by  a  furrow  in  the  concave  surface  of  the  scaphoid.  The  centrale  has  been 
seen  in  more  than  one  piece,  but  I  regard  such  specimens  with  suspicion. 
(For  rare  cases  of  fusion  of  the  epilunatum  with  the  scaphoid  see  the  next 
bone.) 

The  semilunar .  This  bone,  which  gets  its  name  from  its  shape  in  profile, 
has  two  elements  (besides  its  own  centre)  more  or  less  completely  absorbed  into 
it  at  the  tips  of  the  horns.  The  dorsal  one  is  the  epilunatum,  the  palmar  one  the 
hypolunatum.  The  epilunatum  is  very  frequently  clearly  marked  off  by  a  line, 
so  that  it  appears  as  a  knob  on  the  dorsal  horn  at  its  radial  side.  It  occasionally 
is  found  separate,  but  the  largest  specimens  I  have  seen  have  a  very  pathologi- 
cal look.  It  may  join  the  scaphoid  at  its  dorsal  ulnar  angle,  or  it  may  be  seen 
as  a  projection  on  the  dorsal  distal  border  near  the  same  place.  The  semilunar 
as  a  whole  varies  considerably  in  breadth,  but  the  matter  is  of  no  practical 
importance.  I  have  seen  the  semilunar  divided  almost  symmetrically  into  a 
dorsal  and  a  ventral  half.  How  is  this  to  be  explained?  It  might  be  a  fracture, 
and  Pfitzner,  who  has  seen  it  in  a  hand  with  a  broken  fifth  metacarpal,  inclines 
to  think  so ;  but  in  my  case  there  was  no  sign  of  violence.  There  is  no  evi- 
dence offered  by  embryology  nor  by  comparative  anatomy  that  the  semilunar 

1  Consult  Wolff's  discussion  as  to  whether  the  bipartite  and  tripartite  scaphoid  is  the 
result  of  a  fracture,  with  his  report  of  an  instance  of  congenital  division  in  both  hands. 
Deutsche  Zeitschrift  fur  Chirurgie,  Bd.  lxx,  S.  254,    1903. 


6        VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

consists  of  two  elements.1  I  incline  to  explain  it  as  an  overdevelopment  of 
the  epilunatum  and  an  underdevelopment  of  the  chief  bone.  A  large  nutrient 
foramen  entering  at  the  radial  side  and  expanding  into  a  cavity  may  be  a 
source  of  weakness.  The  hypolunatum  on  the  palmar  aspect  is  rare  and  of  little 
practical  importance. 

The  cuneiform.  The  variations  of  this  bone  are  not  very  striking.  They 
are  of  two  kinds :  first,  a  variation  in  the  transverse  diameter  by  which  we  have 
long  and  short  bones,  and,  second,  a  tendency  to  subdivision  by  which  there  are 
more  or  less  clearly  marked  off  a  radial  and  an  ulnar  element  just  as  in  the  sca- 
phoid. These  however  have  never  been  seen  separate  nor  do  they  appear  as  two 
separate  centres.  I  am  not  inclined  to  follow  Pfitzner  in  accepting  them.  He 
points  out  in  further  support  of  his  view  that  besides  the  occasional  appearance 
of  a  line  of  separation  the  two  parts  have  very  different  characteristics,  the 
radial  being  always  about  the  same,  while  differences  in  the  length  of  the  bone 
are  due  entirely  to  the  ulnar  element.  The  epipyramis  is  a  very  rare  bone 
which,  when  separate,  appears  on  the  dorsum  between  the  semilunar,  cunei- 
form and  the  unciform.  It  would  naturally  be  mistaken  for  a  fracture.  Usually 
no  trace  of  this  element  is  to  be  found,  but  it  may  appear  as  a  marking  off  of  the 
dorsal  distal  radial  angle  of  the  cuneiform;  hence  it  is  mentioned  with  that 
bone.     I  have  seen  one  case;  but  a  doubtful  one. 

The  ulnar e  externum,  also  a  very  rare  element,  is  for  the  same  reason  con- 
sidered with  the  cuneiform.  It  is  a  dorsal  element  on  the  ulnar  side  of  the  hand 
situated  between  the  tuberosity  of  the  fifth  metacarpal,  the  unciform,  and  the 
cuneiform.  It  may  be  free  or  it  may  be  fused  with  the  cuneiform.  I  have 
seen  a  case  in  an  X-ray  which  strongly  suggested  it,  but  the  history  of  an  old 
lesion  and  some  disability  in  the  use  of  the  hand  did  not  justify  me  in  accepting 
it.    There  are  two  or  three  specimens  in  the  Harvard  collection. 

The  pisiform  and  the  secondary  pisiform.  The  former  of  these  or  the  pisi- 
form proper  is  a  most  irregular  bone,  not  only  in  size  and  shape,  but  in  position, 
appearing  sometimes  more  proximally,  sometimes  more  distally  situated  than 
visual.  Also  it  seems  sometimes  to  project  very  strongly  beyond  the  ulnar 
side  of  the  hand  while  normally  it  is  wholly  on  the  palmar  side.  These  pecu- 
liarities are  all  more  or  less  exaggerated  in  X-ray  views.  The  secondary  pisi- 
form already  alluded  to  is  found  very  rarely  laid  down  as  a  separated  centre  in 
the  embryo.  Two  centres  of  ossification,  one  distal  to  the  other,  have  been  seen 
by  Debierre2  in  a  girl  of  eleven  and  a  bov  of  twelve.    It  occasionally  appears  as 

1  There  is  an  unconfirmed  statement  by  Serres  that  there  are  two  centres  of  ossifica- 
tion,   near  together  but  finite  distinct. 

2  Contribution    a   l'etude   de   l'Ossification   et  de  l'Homotypie   des  pieces   du  carpe  et 
du  tarse  chez  l'homme.     Journal  de  l'Anatomie  et  de  la  Physiologie,  Tome  22,  1886. 


THE  HAND— VARIATIONS  AND  ADDITIONAL  BONES  7 

a  proximal  prolongation  of  the  pisiform,  sometimes  making  a  second  swelling. 
I  have  one  hand  in  which  the  pisiform  has  every  appearance  of  having  lost  this 
element.  There  is  a  proximal  surface  overhung  by  the  palmar  projection  of  the 
bone  which  has  the  character  of  a  surface  to  which  a  bone  has  been  fastened  by 
non-articular  cartilage.  Though  the  case  must  be  doubtful  I  strongly  incline 
to  think  that  in  this  instance  this  element  was  really  present  and  lost  before  I 
examined  the  specimen.  This  element  should  (I  think)  be  shown  by  lateral 
X-ray  views. 

The  trapezium  presents  very  little  of  interest.  Perhaps  the  most  important 
feature  is  the  degree  of  development  of  the  ridge  which,  usually  small,  is  occa- 
sionally very  prominent,  suggesting  the  hook  of  the  unciform.  The  distal  end 
of  this  may  be  represented  by  a  small  separate  bone,  the  prcetrapezium.  I  have 
a  pair  of  hands  showing  it  on  both  sides.  It  not  very  rarely  appears  as  a  knob 
on  the  ridge.  Pfltzner  long  doubted  whether  to  consider  the  angle  of  the  tra- 
pezium between  the  bases  of  the  first  and  second  metacarpals  as  a  true  element. 
He  has  decided  to  do  so  and  has  named  it  the  trapezium  secundarium.  It  is 
excessively  uncommon,  except  under  very  pathological  conditions,  in  which  I 
have  seen  hints  of  it  several  times  and  I  think  once  at  least  have  found  it  dis- 
tinct. Usually  I  have  found  it  with  a  distortion  of  the  metacarpal  of  the  thumb 
and  with  a  flattening  of  the  socket.  I  have  seen  no  case  myself  that  was  not 
pathological.  It  is  worth  while,  however,  to  recognize  the  possibility  of  a  dis- 
tinct bone  in  this  place  under  such  conditions. 

The  epitrapezium,  on  the  dorsal  side  next  to  the  scaphoid,  has  once  been  seen 
separate  by  Zuckerkandl.  I  have  seen  a  prominent  projection  on  the  dorsum 
which  may  be  explained  as  this  element.  It  is  apparently  not  infrequent  in 
anthropoids. 

The  paratrapezium,  forming  the  outer  distal  angle,  has  also  been  seen  sepa- 
rate only  once.     The  observation  is  by  Cuyer.1 

The  trapezoid  has  been  found  a  few  times  divided  into  a  dorsal  and  a  pal- 
mar half,  the  latter  reaching  the  dorsum  at  the  radial  side.  This  bone  shows  so 
badly  in  the  ordinary  X-ray  view,  owing  to  the  position  of  the  trapezium  over- 
lapping it,  that  its  study  leads  to  little  of  practical  importance.  Sometimes 
the  styloid,  of  which  more  later,  is  fused  with  it. 

The  os  magnum  shows  considerable  minor  variations  of  shape  and  size. 
Perhaps  the  most  striking  is  the  change  of  the  distal  dorsal  border  from  oblique 
to  transverse  when  the  styloid  (discussed  with  the  third  metacarpal)  is  fused 
with  it.  There  is  also  considerable  variation  on  its  radial  side  in  the  depth  of 
the  fossa  occupied  by  the  centrale  when  it  is  present  as  a  distinct  bone  or  as  an 


1  Bull.  Soc.  d'Anthropol.  Paris,   1887,  p.  303. 


8         VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

offshoot  of  the  scaphoid.  The  os  magnum  consists  theoretically  of  three  bones: 
the  proprium  which  is  the  main  bone,  the  capitatum  secundarium  which  is  the 
distal  ulnar  dorsal  angle,  and  the  subcapitatum  which  is  the  swelling  on  the  dis- 
tal end  of  the  palmar  surface.  This  last  is  a  monument  to  Pfitzner.  He  had 
described  the  three  parts  of  the  os  magnum  as  marked  off  on  several  specimens, 
but  he  never  found  a  subdivided  magnum  himself.  The  capitatum  secunda- 
rium is  not  rarely  indicated  on  the  dorsum.  It  has  been  seen  as  a  separate 
bone  only  twice,  once  by  Gruber1  of  St.  Petersburg  and  once  by  Lamb2  of  Wash- 
ington. Undoubtedly  it  will  be  shown  sometime  by  the  X-ray  and  will  suggest 
a  fracture,  provided  always  that  the  focus  be  such  as  to  show  the  dorsum, 
which  is  not  usually  the  case.  Some  bones  show  it  and  the  styloid  as  two  knobs. 
The  swelling  on  the  palmar  side  made  by  the  subcapitatum  varies  very  much  in 
different  bones  and  consequently  in  X-rays.  Sometimes  they  show  the  outline 
very  clearly.  The  author3  is  the  only  one  who  has  had  the  fortune  to  find  this 
element  separate.  He  observed  it  after  Pfitzner's  death  on  both  hands  of  one 
body.  Very  certainly  there  is  no  possibility  of  a  fracture;  but  the  separate 
bone  is  considerably  smaller  than  was  to  be  expected.  Probably  the  X-ray  at 
the  proper  focus  would  show  this  bone,  just  as  it  does  the  swelling  which  nor- 
mally represents  it,  but  it  is  hardly  conceivable  that  it  should  show  it  as  a  dis- 
tinct  element. 

Gruber' s  ossicle,  excessively  rare,  of  which  I  have  no  personal  knowledge, 
is  a  little  pyramid  with  the  base  on  the  palmar  side  of  the  hand  and  the  apex 
plunging  into  the  space  between  the  third  and  fourth  metacarpals  and  the  os 
magnum   and   unciform. 

The  unciform  is  composed  of  two  parts,  which  may  have  separate  centres 
in  the  prascartilaginous  stage,  and  also  separate  centres  of  ossification,  the  bone 
proper  and  the  hamular  process,  os  hamuli.  As  we  are  not  working  scientifically 
but  practically,  and  as  this  is  one  of  the  greatest  puzzles  of  the  whole  question,  I 
shall  leave  explanations  quite  aside.  The  variations  of  the  bone  of  practical 
importance  are  pretty  nearly  limited  to  the  hook,  which  may  be  small  or  large, 
sometimes  rather  weak  and  triangular,  when  seen  from  the  side,  and  again  very 
long  and  square-cornered.  Of  most  practical  interest  are  the  cases  in  which  the 
hook  is  distinct.  This  may  occur  in  such  a  way  that  the  whole  hook  is  sepa- 
rate and  well-formed.  This  is  easily  explained  by  a  separate  centre  for  the  hook, 
which  Thilenius  has  observed;  but  there  may  be  a  small  longitudinal  ridge 
like  the  base  of  a  hook  and  on  this  a  free  terminal  piece,  usually  underdeveloped, 
or  this  terminal  piece  may  be  wanting.     I  have  seen,  I  believe,  all  of  these  con- 


1  Melanges   Biol.,   vii,    1870. 

2  Washington    Medical   Annals,    vol.   iii,    1904. 

3  Anat.  Anzeiger,  Bd.  xxiv,  S.  253,  1904. 


THE  HAND— VARIATIONS  AND  ADDITIONAL  BONES  9 

ditions  in  bones,  but  have  never  met  with  any  convincing  X-ray.  A  side  view 
would  suggest  fracture. 

There  remain  five  bones  of  the  carpus,  four  of  which,  the  secondary 
trapezoid,  the  parastyloid,  the  styloid,  and  the  bone  of  Vesalins,  are  in  closest 
connection  with  the  metacarpal  bones  and  shall  be  considered  with  them;  while 
the  fifth,  the  metastyloid ,  shall  be  taken  after  the  styloid. 

The  metacarpals.  Apart  from  the  variations  depending  on  the  bones  just 
mentioned  there  is  not  much  to  say  about  the  metacarpals.  There  is  a  long 
type  and  a  short  type;  but  the  latter  is  the  more  important  as  sometimes  the 
reduction  in  length  is  very  considerable,  amounting  to  at  least  half  the  ordi- 
nary length.  Two  or  three  fingers  may  be  affected,  the  condition  occurring  in 
both  hands,  though  without  perfect  symmetry.  A  remarkable  case  of  short- 
ening of  the  fifth  metacarpal  is  mentioned  in  the  section  on  fusion  of  bones. 
The  human  metacarpals  ossify  from  a  centre  for  the  shaft  and  an  epiphysis 
which  is  in  the  proximal  end  of  the  first  metacarpal  and  in  the  distal  end  of 
the  others.  Exceptionally  an  epiphysis  is  found  in  the  proximal  end  of  those 
of  the  fingers.  Whether  it  is  a  true  epiphysis  or  has  a  very  slender  connection 
with  the  centre  for  the  shaft  may  be  disregarded,  for  it  has  all  the  outer 
appearance  of  a  true  epiphysis  and  seen  by  the  X-ray  might  be  mistaken  for 
a  fracture.  That  of  the  index  finger  seems  to  be  the  most  common.  I  have  seen 
it  once  in  the  skiagraph  of  a  boy  of  fifteen  and  it  is  figured  twice  in  Grashey's 
atlas. 

The  secondary  trapezoid,  found  on  the  dorsum,  represents  the  tip  of  the 
radial  side  of  the  base  of  the  second  metacarpal  resting  against  the  trapezium 
and  the  trapezoid.  It  has  been  seen  five  times  as  a  distinct  bone  with  articu- 
lar surfaces.  It  is  therefore  not  the  result  of  a  fracture.  Pfitzner  has  seen  it 
marked  off  by  a  line  from  the  metacarpal. 

The  parastyloid,  once  found  free,  is  the  ulnar  projection  on  the  dorsum  of 
the  base  of  the  second  metacarpal. 

The  styloid  is  the  most  frequent  of  these  extra  bones  in  the  hand  and  illus- 
trates most  perfectly  Pfitzner's  views.  It  is  found  in  some  69  per  cent,  of  young 
embryos  as  a  separate  centre  which  habitually  fuses  with  the  third  metacarpal, 
forming  its  styloid  process  slanting  obliquely  between  the  trapezoid  and  the  os 
magnum.  It  may  be  distinct  with  articular  surfaces,  or  fused  with  either  of 
these  bones.  When  it  fuses  with  the  os  magnum  the  distal  line  on  the  dorsum 
of  the  latter  is  practically  transverse.  In  the  ordinary  X-ray  taken  with  the 
hand  prone  the  focus  is  such  that  we  get  the  view  of  the  palmar  aspect.  The 
second  metacarpal  is  seen  astride  of  the  trapezoid,  and  the  styloid  is  usually 
impossible  to  define.  I  have  seen  however  in  X-rays  the  transverse  distal  border 
of  the  os  magnum  which  is  characteristic  of  a  fused  styloid  and  I  have  two  or 


10  VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

three  times  seen  a  separate  styloid  though  not  very  distinctly.  In  bones  I  have 
seen  many  forms.  Pfitzner  made  one  curious  observation  concerning  the  rela- 
tive arrangement  of  the  bones  in  each  hand.  The  styloid  may  be  fused  with 
the  third  metacarpal  in  one  hand  and  with  either  the  os  magnum  or  the  trape- 
zoid in  the  other;  but  it  never  is  fused  with  the  trapezoid  in  one  hand  and  with 
the  os  magnum  in  the  other.  When  it  is  fused  with  the  trapezoid  it  gives  the 
latter  a  curious  transverse  elongation.  It  may  be,  as  above  stated,  in  relation 
with  the  bones  in  question  by  a  true  joint  or  a  true  bony  connection,  or  in  place 
of  the  latter  the  connection  may  be  by  fibro-cartilage.  In  1450  hands  Pfitzner 
found  it  connected  one  way  or  the  other  with  the  metacarpal  in  1397,  with  the  os 
magnum  in  54,  and  with  the  trapezoid  in  16.  This  series  of  course  includes  cases 
of  its  being  connected  with  more  than  one  of  these  bones.  As  I  have  determined 
to  avoid  purely  scientific  discussion  in  this  work,  I  shall  merely  make  the  bare 
statement  that  I  have  seen  the  styloid  more  than  once  in  two  places  in  the  same 
hand;  as,  for  instance,  represented  by  a  swelling  on  both  the  metacarpal  and 
the  os  magnum.  I  mention  this  only  because  the  fact  is  worth  noting  from  its 
practical  importance. 

The  metastyloid  is  an  uncommon,  and  practically  unimportant  ossicle  in 
the  dorsum  between  the  point  of  the  styloid  process  of  the  third  metacarpal 
and  the  os  magnum  and  trapezoid.  It  may  be  free  or  fused  with  either  of  the 
others.  Pfitzner  speaks  of  its  maximum  size  being  5.5  mm.,  but  usually  it  is 
quite  insignificant.  I  have  a  specimen  of  about  5  mm.  diameter  coalesced  with 
the  trapezoid  but  plainly  marked  off. 

The  Vesaliamtm  or  bone  of  Vesalius  is  the  tip  of  the  ulnar  side  of  the  base 
of  the  fifth  metacarpal.  It  is  situated  between  the  metacarpal  and  the  unci- 
form, or  it  may  be  prolonged  from  the  former  to  lie  on  the  outer  side  of  the 
latter.  It  is  named  after  Vesalius  because  he  described  it  as  a  constant  ele- 
ment, considering  it  a  sesamoid.  It  has  been  seen  several  times,  if  not  free, 
at  least  plainly  marked  off  on  the  base  of  the  metacarpal.  I  have  seen  an  X-ray 
in  which  apparently  it  was  wanting.  In  fact  it  may  have  remained  cartilagi- 
nous. The  size  of  the  tuberosity  of  the  fifth  metacarpal  varies  widely  quite 
independently  of  the  bone  of  Vesalius,  which  represents  only  a  part  of  it. 

The  phalanges  also  may  be  longer  or  shorter  than  normal.  Lengthening 
when  there  is  no  question  of  compensation  is  not  common  nor  very  noticeable. 
I  incline  without  categorical  proof  to  think  it  more  frequent  in  negroes.  An 
extra  phalanx  is  found  very  rarely  in  the  thumb.  In  the  case  of  a  family 
recorded  by  Rieder,1  the  middle  phalanx  ranged  from  a  well-formed  one  to  a 
small  rudiment  larger  on  one  side  than  on  the  other,  so  as  not  to  separate  com- 


1  Deutsche   Archiv    fi'ir    klin.  Med.,  Bd.  66. 


THE  HAND— VARIATIONS  AND  ADDITIONAL  BONES  H 

pletely  the  proximal  and  distal  phalanges.  The  extra  phalanx  seems  to  tend  to 
be  absorbed  into  the  terminal  one.  The  oblique  line  of  separation  might  be 
mistaken  for  a  fracture  in  an  X-ray  plate.  In  no  case  did  the  extra  phalanx 
have  an  epiphysis  in  those  of  an  age  at  which  it  is  to  be  expected.  Shortening 
and  suppression  of  phalanges  occurs  apparently  most  often  in  the  middle  row, 
the  one  in  which  ossification  appears  last.  This  condition  is  associated  with 
webbed  fingers.  The  phalanges  of  the  last  row  are  sometimes  small  and  ill- 
developed.  Pfitzner  calls  the  attention  of  anthropologists  particularly  to  some 
cases  in  which  the  last  phalanx  of  the  thumb  is  about  one  third  shorter  than 
usual  but  beautifully  formed. 

Sesamoid  bones  of  the  hand.  It  has  been  already  stated  that  these  are  more 
numerous  in  the  foetus  than  later.  We  assume  that  there  is  originally  in  the 
human  hand  a  pair  at  each  metacarpo-phalangeal  joint,  though  all  have  not 
yet  been  observed.  The  following  table  is  taken  from  Pfitzner.  The  first  row 
shows  the  percentage  found  by  Thilenius1  in  30  hands  of  embryos  of  the  fourth 
month,  and  the  second  row  the  percentage  in  1440  hands  from  fourteen  years 
up  to  eighty-nine  as  found  by  Pfitzner.  In  order  to  name  each  bone  it  is  easier 
to  call  those  of  each  finger  the  radial  and  the  ulnar  sesamoid  rather  than  the 
outer  and  inner.    The  Roman  numerals  indicate  the  finger,  including  the  thumb 

as  I. 

I.  II.  III.  IV.  V. 

R.  U.  R. 

Embryos.  .  (100         100)  (46 
Adults    ...(  99.9     100)  (48.7 

It  is  easy  to  infer  from  this  that  the  most  common  arrangement  in  the  adult 
is  that  presenting  two  in  the  thumb,  one  on  the  radial  side  of  the  index  and  one 
on  the  ulnar  side  of  the  little  finger.  A.  Stieda2  has  since  found  with  the  X-ray 
a  radial  sesamoid  in  the  fourth  finger  in  two  hands. 

Subdivision  of  the  radial  sesamoid  of  the  thumb.  Pfitzner  found  this  three 
times,  once  in  both  hands  of  the  same  body,  which  pretty  well  excludes  frac- 
ture. He  once  also  in  an  individual  of  seventeen  years  found  the  two  pieces 
united  by  a  strip  of  cartilage.  They  lie  side  by  side,  but  there  is  a  tendency  for 
the  radial  one  to  be  placed  somewhat  more  proximally  than  its  fellow. 

A  sesamoid  bone  between  the  first  and  second  phalanges  is  found  frequently 
in  the  thumb  opposite  the  middle  of  the  joint.  Pfitzner  believed  it  to  consist 
of  two  lateral  elements  fused.  He  once  found  it  in  two  pieces,  but  the  specimen 
was  not  above  suspicion.  Discarding  that,  however,  he  found  it  three  times, 
twice  on  each  hand  of  one  body,  with  a  furrow  dividing  two  equal  lateral  halves. 

1  Morph.  Arbeiten,  Bd.  v,  S.  319. 

2  Beitrage  zur  klin.  Chirurg.,   1904. 


U.               R. 

U.          R.        U.            R. 

u. 

23    )  (3° 

15)  (23     3°    )  (8 

84  ) 

0.1)  (    1.4 

0)  (   0        0.1)  (2.1 

82.5) 

12  VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

In  time  it  will  doubtless  be  found  in  two  pieces.     Once  Pfitzner  found  a  corre- 
sponding bone  in  the  index. 

Sesamoid  bones  on  the  dorsum,  at  the  metacarpo-phalangeal  joints,  are 
observed  in  certain  orders  of  mammals,  but  in  man  have  been  seen  only  twice, 
both  in  the  thumb,  once  by  Pfitzner  and  once  by  Kulmus.1  The  former 
describes  his  case  as  a  globular  ossicle  of  1.5  mm.  diameter  in  the  posterior 
wall  of  the  capsule. 

FUSION  OF  BONES  OF  THE  HAND. 

Fusion  of  the  scaphoid  and  semilunar  after  the  fashion  of  the  carnivora 
has  apparently  not  been  observed  in  man.  I  have  never  seen  it  without  still 
more  extensive  fusions  which  pass  the  limit  of  ordinary-  variation. 

Fusion  of  the  semilunar  and  cuneiform.  According  to  my  own  observations 
the  fusion  of  these  elements  is  always  bony.  There  are,  however,  cases  in  which, 
though  a  true  joint  is  wanting  between  the  pieces,  they  may  be  separated  by 
maceration.  The  union  almost  always  occurs  at  the  proximal  surface  of  the 
bones  at  the  place  where  they  are  normally  connected  by  an  interosseous  liga- 
ment. Almost  always  there  is  a  furrow  on  the  distal  surface  marking  the  orig- 
inal line  of  separation.  Exceptionally  the  union  is  perfect  throughout.  Pfitzner 
once  saw  it  at  the  distal  dorsal  end.  The  hands  which  I  have  observed  show  abso- 
lutely nothing  pathological.  This  fusion  should  be  shown  by  the  X-ray,  but  I 
am  not  aware  that  it  has  ever  been  so  observed.  Pfitzner  has  pointed  out  the 
relative  frequency  of  this  condition  in  the  blacks.  He  had  collected  the  accounts 
of  fifteen  cases,  six  being  his  own,  of  which  five  were  from  negroes.  Since  then 
Prof.  G.  Elliot  Smith2  observed  fusion  in  both  hands  of  a  Soudanese  negro. 
Still  later  Dr.  Derry3  announced  that  Smith  had  since  observed  it  three  times 
in  six  individuals  of  the  same  race.  It  was  present  in  both  hands  of  a  woman 
and  in  one  of  a  man,  whose  other  hand  was  not  examined.  I  have  met  with 
it  six  times:  once  in  both  hands  of  a  negro,  twice  in  one  hand  of  a  negro  or 
mulatto,  one  male  the  other  female,  and  twice  in  hands  of  unknown  origin. 
Thus  of  twenty-six  observed  cases  at  least  fourteen  are  from  blacks.4 

Fusion  of  the  cuneiform  and  pisiform.  There  is  but  one  observation5  of 
fusion  of  these  bones  when  they  were  the  only  ones  affected.     It  occurred  on 


1  Tabulae  Anatomicae,  Amsterdam,    1732. 

2  On  a  Case  of  Numerical  Reduction  of  the  Carpus,  Anat.  Anzeiger,  Bd.  xxiii,  1903. 

3  Journ.  of  Anat.  and  Phys.,  vol.  xli,   1906. 

1  Since  the  above  was  written  a  ease  of  very  complete  fusion  of  these  bones  in  the  right 
hand  of  a  white  man  is  reported  by  A.  A.  M'Connell  in  the  July,  1907,  number  of  the  Journ. 
of  Anat.  and  Phys.,  vol.  xli.     The  left  hand  was  normal. 

r'  Wedding,  Dissertation,   Berlin,   1832. 


FUSION    OF    BONES    OF    THE    HAND  13 

both  sides.  It  is  worth  mentioning  that  in  cases  of  general  fusion  (presumably 
pathological)  of  the  carpus  these  two  bones  are  the  last  to  unite. 

Fusion  of  the  trapezoid  and  the  scaphoid.  Complete  fusion  has  once  been 
noted  by  Turner.1 

Fusion  of  the  trapezoid  and  os  magnum.  These  have  been  seen  joined  at 
the  dorsum  both  by  bone  and  by  fibro-cartilage,  by  both  Pfitzner  and  Ander- 
son.2 

Fusion  of  os  magnum  and  unciform.  This  has  been  seen  only  by  Pfitzner, 
once  in  both  hands  and  once  in  an  odd  hand.  The  union  appears  to  have  been 
complete  except  for  a  furrow  on  the  distal  side. 

Fusion  of  the  second  metacarpal  with  the  trapezoid.  Pfitzner  has  seen  these 
bones  joined  by  fibro-cartilage  in  three  cases.  I  have  seen  bonv  union  at  least 
once.  Though  there  were  no  clear  signs  of  disease  in  other  places,  the  speci- 
men has  a  pathological  look. 

Fusion  of  the  third  metacarpal  with  the  os  magnum  and  trapezoid.  Fusion 
with  the  os  magnum  has  been  observed  so  far,  I  believe,  only  when  the  union 
was  cartilaginous.  It  may  occur  by  means  of  the  styloid,  but  not  necessarily. 
Fusion  with  the  trapezoid  may  occur  through  the  styloid  or  otherwise  and  may 
be  either  bony  or  cartilaginous.  I  have  one  specimen  in  which  the  dorsal  parts 
of  the  bones  had  evidently  been  joined  by  cartilage.  Solger3  found  the  car- 
tilage of  the  os  magnum  and  third  metacarpal  continuous  in  an  infant. 

General  fusion  of  the  bones  of  the  wrist,  so  far  as  I  have  observed,  is  either 
terato logical,  as  in  cases  of  extra  fingers,  or  pathological.  Still  there  is  room 
for  doubt.  I  have  a  hand  (of  uncertain  origin)  in  which  the  scaphoid  is  fused 
with  the  semilunar,  the  second  metacarpal  with  the  trapezoid,  and  the  third 
metacarpal  with  the  os  magnum,  chiefly  through  the  styloid.  It  is  patho- 
logical. 

Fusion  of  the  fourth  and  fifth  metacarpals.  I  have  seen  this  once  in  a  nor- 
mal left  hand,  the  bones  being  united  for  about  one-third  of  their  length  at  the 
proximal  end.  I  give  a  figure  of  a  similar  condition  observed  in  both  hands  of 
a  lad  of  eighteen,  only  the  fusion  was  somewhat  greater  and  the  distal  end  of 
the  fifth  metacarpal  undeveloped  so  that  the  bone  was  not  more  than  two- 
thirds  of  its  proper  length.  With  this  in  my  mind  I  reexamined  the  bony  speci- 
men and  convinced  myself  that  the  fifth  metatarsal  is  a  little  shorter  than 
usual. 

1  Some  Variations  in  the  Bones  of  the  Human  Carpus,  Journ.  of  Anat.  and  Phys.,  vol. 
xvii,    1883. 

2  Division  of  the  Scaphoid  Bone  of  the  Carpus,  with  Notes  on  other  Varieties  of  the 
Carpal  Bones,  Ditto,  1883. 

3  Centralblatt  der  allg.  Path,  und  Path.  Anat.,  Bd.  i,  1890. 


14       VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

THE  FOOT. 

No  time  is  to  be  spent  in  attempting  an  arrangement  of  the  tarsal  bones 
into  transverse  and  longitudinal  rows,  nor  in  discussing  their  homologies  with 
those  of  the  carpus.  There  are  in  the  foot  as  in  the  hand  a  number  of  occa- 
sional bones  to  be  accounted  for  by  the  persistence  of  embryonic  elements 
which  normally  lose  their  individuality  by  early  fusion  or  by  disappearance. 
It  is  to  be  noted  that  two  elements  of  the  theoretical  tarsus  are  described  in 
human  anatomy  as  sesamoid  bones,  namely  those  of  the  tendons  of  the  tibi- 
alis posticus  and  peroneus  longus.  In  the  following  list  I  have  followed  Pfitzner 
much  less  closely  than  in  the  hand,  omitting  several  elements  which  he  names, 
but  concerning  some  of  which  he  has  well-founded  doubts  as  to  whether  they 
are  not  pathological,  and  others  which  while  not  pathological  have  never  been 
seen  separate. 

i .  Trigonum.  This  is  the  external  posterior  process  of  the  astragalus 
(or  a  part  of  it).  2.  The  astragalus.  3.  The  os  calcis.  4.  Os  sustentaculi ,  the 
posterior  end  of  the  sustentaculum.  5.  The  peroneal  spine.  The  process  on  the 
outer  side  of  the  os  calcis  separating  the  tendons  of  the  peroneus  longus  and 
brevis.  The  Germans  name  it  processus  trochlear  is  calcanei.  (It  is  not  certain 
that  this  is  a  distinct  element.)  6.  Calcaneum  secundarium  (secondary  os  calcis), 
the  anterior  superior  angle  of  the  os  calcis  situated  at  the  point  where  that  bone 
and  the  astragalus  meet  (approximately)  the  scaphoid  and  cuboid.  7.  Tibiale 
externum,  commonly  known  as  the  sesamoid  bone  in  the  tendon  of  the  tibialis 
posticus.  8.  The  scaphoid.  9.  Cuboides  secundarium  (secondary  cuboid) ,  com- 
monly fused  with  either  the  cuboid  or  the  scaphoid  in  the  sole  of  the  foot  where 
these  bones  nearly  meet.  10  and  1 1 .  Internal  cuneiform,  subdivided  into  (1 )  a  dor- 
sal and  (2)  a  plantar  part.  12.  Intercuneiform.  A  bone  on  the  dorsum  between 
the  proximal  ends  of  the  internal  and  middle  cuneiforms  resting  against  the 
scaphoid.  13..  Middle  cuneiform.  14.  External  cuneiform.  15.  Cuboid.  16. 
Peroneum.  This  is  very  rarely  found  in  bone  or  true  cartilage;  it  is  represented 
by  the  thickening  in  the  tendon  of  the  peroneus  longus  and  is  called  a  sesamoid 
bone.  17.  I ntcrmetatarseum.  A  bone  situated  at  the  junction  of  the  internal 
cuneiform  and  the  first  and  second  metatarsals.  18.  Vesalianum,  the  tip  of 
the  tuoerosity  of  the  fifth  metatarsal. 

We  shall  now  consider  the  several  bones  together  with  the  occasional  ele- 
ments which  are  most  intimately  associated  with  them,  at  the  same  time  call- 
ing attention  to  the  other  variations  of  the  regular  bones.  Then  we  shall  deal 
with  the  fusions  of  the  bones  and  their  uncommon  relations. 


THE    FOOT  15 

VARIATIONS  AND  ADDITIONAL  BONES. 

The  astragalus  and  trigonum.  The  hind  part  of  the  astragalus  is  drawn 
out  backwards  into  a  projection,  grooved  by  the  tendon  of  the  flexor  hallucis 
muscle,  which  runs  obliquely  downwards  from  without  inward.  The  outer 
border  of  this  groove  is  made  by  the  posterior  external  tubercle.  The  inner  border 
may  be  very  ill-defined  or  may  be  marked  by  the  posterior  internal  tubercle. 
The  external  tubercle  on  the  outer  border  of  the  groove  has  not  the  slightest 
mechanical  function  unless  perhaps  that  it  prevents  the  tendon  from  falling 
outwards  during  the  total  relaxation  of  the  muscle.  Certainly  when  the  muscle 
is  contracting,  the  tubercle  is  of  no  value.  On  the  outer  side  of  this  tubercle  is 
the  trigonum,  which  in  some  7  or  8  per  cent,  is  a  distinct  bone.  Its  lower  surface 
continues  the  articulation  of  the  astragalus  with  the  os  calcis.  As  the  question 
of  fracture  is  brought  up  in  connection  with  this  occasional  bone,  it  is  proper  to 
show  what  are  its  claims  to  be  considered  a  part  of  the  skeleton.1  v.  Bardele- 
ben  found  it  a  distinct  piece  of  cartilage  in  the  second  month  of  embryonic 
life,  situated  between  the  bones  of  the  leg.  It  is  therefore  homologous  with 
the  triangulare.  I  have  found  it  distinct  in  cartilage  at  birth.  It  is  hardly  to 
be  found  in  animals  except  in  the  marsupials,  but  is  constant  in  those  of  that 
order  which  have  five  toes.  As  to  its  size  and  development  it  is  very  variable. 
It  has  been  seen  hooking  over  the  groove.  It  may  represent  practically  the 
whole  of  the  external  posterior  process.  Though  Pfitzner  has  never  seen  it 
make  the  actual  border  of  the  groove,  I  incline  to  think  it  may  do  so.2  On 
the  other  hand  there  may  be  a  very  long  process  with  the  trigonum  situated 
at  its  end.     An  instance  is  shown  in  fig.  35. 

Pfitzner  insists  very  strongly  that  it  is  not  the  same  thing  as  the  tubercle. 
Very  rarely  it  has  been  found  in  two  pieces.  I  have  such  a  specimen  which  offers 
no  suggestion  of  violence.  When  it  is  free  it  is  generally  joined  to  the  astraga- 
lus by  a  little  fibro-cartilaginous  tissue,  the  bony  surfaces  being  in  close  apposi- 
tion. Exceptionally  there  may  be  a  true  joint.  Sometimes  the  union  may  be 
by  cartilage.  When  it  is  truly  fused  so  that  there  is  but  one  bone  the  outline 
of  the  trigonum  may  be  perfectly  clear,  or  very  hard  to  make  out.  The  trigonum 
tends  to  be  in  the  main  symmetrical,  but  may  be  distinct  on  one  side  and  fused 
on  the  other.  The  statistics  of  the  frequency  of  the  trigonum  are  very  unsat- 
isfactory; first  because  there  is  a  discrepancy  in  the  use  of  terms.  Pfitzner 
speaks  of  separate  (selbstandige)  trigona.     Sewell  speaks  of  "evidence  of  sepa- 

1  Weber,  Das  Intermedium  Tarsi.  Sitzungsbericht.  Jenaisehe  Gesellschaft  fur  Mediein 
und  Naturwissen,  1883. 

2  Consult  Sewell,  A  Study  of  the  Astragalus,  Journ.  of  Anal,  and  Phys.,  vol.  xxxviii. 
p.  426.     This  series  of  papers  on  the  astragalus  is  continued  in   the  two   following  volumes. 


16      VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

ration,"  which  is  an  indefinite  term.  Again,  not  only  fused,  though  clearly 
marked  off,  trigona  may  be  easily  overlooked,  but  a  free  one  may  be  so  closely 
joined  bv  synchondrosis  as  not  to  be  recognized  without  great  care.  Pfitzner 
put  the  frequency  at  from  7  to  8  per  cent.,  basing  his  judgment  on  specimens 
which  he  himself  had  thoroughly  examined  and  rejecting  series  which  most  other 
men  would  have  accepted.  It  is  therefore  very  common.  Bearing  in  mind  what 
has  been  said  of  the  embryology  and  comparative  anatomy,  no  one  now  would 
seriously  maintain  that  it  is  the  result  of  a  fracture.  It  cannot  indeed  be  denied 
that  a  trigonum  loosely  attached  might  be  broken  off,  but  it  is  so  sheltered  that 
it  is  hard  to  see  how  this  accident  should  occur.  It  is  supposable  that  it  might 
be  pulled  off,  especially  if  originally  distinct,  by  the  strain  of  the  posterior 
bundle  of  the  external  lateral  ligament  of  the  ankle.1  It  is  often  very  well 
shown  by  the  X-ray,  but  probably  when  the  connection""  is  a  close  one  it  may  be 
difficult  to  recognize. 

The  posterior  internal  tubercle,  though  usually  small  or  even  absent,  is  excep- 
tionally very  strongly  developed.  It  cannot  be  accounted  for  by  any  element 
which  is  usually  wanting.  It  therefore  is  simply  a  case  of  hypertrophy  of  a  part 
of  the  skeleton  for  which  there  is  no  satisfactory  explanation.  It  might  perhaps 
pass  as  one  of  Hyrtl's  trochlear  or  pulley-like  processes,  as  the  tendon  of  the 
flexor  hallucis  plays  on  it.  The  astragalus  shows  occasionally  an  upward  pro- 
jection from  the  dorsum  just  behind  the  head.  Hyrtl  described  it  as  one  of  his 
trochlear  processes.  It  has  a  distinctly  pathological  appearance  suggesting  an 
exostosis.  There  is,  however,  a  certain  family  likeness  between  specimens.  Be 
the  cause  of  the  process  what  it  may,  it  is  worth  knowing  that  it  occurs. 

The  astragalus  (and  the  same  may  be  said  of  the  os  calcis)  is  a  very  vari- 
able bone  in  respect  to  its  general  conformation.  It  may  be  long  and  narrow  or 
short  and  broad;  the  neck  may  diverge  much  or  little  from  the  axis  of  the  body, 
the  shape  and  inclination  of  the  head  are  very  uncertain.  It  can  hardly  be 
doubted  that  these  variations  must  have  an  important  influence  on  the  shape 
of  the  foot  and  on  its  movements.  But  the  genius  who  should  work  this  out  has 
not  yet  appeared.  Parker  and  Shattock2  reckoned  the  angle  of  the  neck,  that 
is  its  lateral  divergence,  as  the  angle  formed  by  a  line  parallel  with  the  inner 
border  of  the  superior  articular  surface  and  one  parallel  with  the  outer  border 
(jf  the  neck.  The  inclination  to  the  side  as  shown  by  this  angle  is  much  greater 
in  the  anthropoids  than  in  man.  The  human  foetus  in  this  respect  resembles 
the  apes.  These  observers  found  the  average  angle  in  twenty  adults  10.65, 
the  maximum  being  26  and  the  minimum  too  little  to  be  measured.    In  the  fcetus 

1  Vollbrecht.  Fortschr.  a.  d.  Gebiet.  d.  Rontgenstrahlen,  1900. 

2  Pathology  and  Etiology  of  Club-Foot,  Trans.  Path.  Soc.  of  London,  vol.  xxxv,  1884. 


THE    FOOT— VARIATIONS    AND    ADDITIONAL    BONES  17 

from  the  fourth  month  to  term  the  average  angle  of  eleven  cases  was  38,  the 
maximum  42  and  the  minimum  35.  The  series  is  of  course  too  small  to  show 
anything  more  than  the  main  fact. 

The  os  calcis,  the  os  sustentacula,  the  peroneal  spine,  and  the  secondary  os 
calcis.  The  first  of  these  exceptional  bones,  the  os  sustentacidi,  forming  the  hind 
end  of  the  sustentaculum,  is  very  uncommon.  Pfitzner  has  seen  it  twice  as  a  dis- 
tinct bone,  connected  by  fibro-cartilage,  or  fibrous  tissue,  and  has  several  times 
been  able  to  recognize  its  presence  although  it  was  fused.  I  have  never  seen  it 
separate.  It  is  of  no  practical  importance  (except  as  concerned  in  fusion  of  the 
astragalus  and  os  calcis,  of  which  later),  and  would  be  hard  to  show  with  the 
X-ray. 

The  peroneal  spine  {processus  trochlearis  of  German  anatomists)  is  gener- 
ally described  as  a  small  ridge  on  the  outer  side  of  the  os  calcis  separating  the 
tendons  of  the  peroneus  longus  and  brevis.  In  point  of  fact  it  is  found  even  tol- 
erably developed  so  as  to  be  distinctly  discernible  in  only  about  40  per  cent,  of 
feet  according  to  Pfitzner,  Gruber,  and  Stieda.  The  first  of  these  thought  he 
saw  evidence  once  or  twice  of  its  having  once  been  a  separate  bone,  but  there  is 
not  much  to  be  said  in  support  of  this  view.  It  is  more  probably  to  be  con- 
sidered (like  the  internal  posterior  process  of  the  astragalus)  one  of  those  pro- 
cesses often  absent  and  occasionally  greatly  developed.  It  is  shown  in  several 
of  these  illustrations.  The  museum  has  one  specimen  in  which  it  is  much  larger 
than  usual ;  but  it  must  be  owned  that  it  has  the  appearance  of  being  at  least 
in  part  formed  by  a  pathological  ossification  of  the  fibrous  tissue  separating  the 
tendons.  Such  a  structure  might  be  mistaken  during  life  for  an  exostosis. 
Another  much  more  important  specimen  from  a  negro,  who  presented  the  same 
appearance  on  both  sides,  shows  it  as  a  truly  immense  projection  from  the  side 
of  the  os  calcis,  so  as  to  be  less  a  process  than  a  large  part  of  the  bone.  It 
recalls  very  strongly  the  appearance  presented  by  the  chimpanzee  alone  among 
anthropoid  apes.  Pfitzner  figures  a  similar  but  perhaps  less  striking  case  which 
was  present  in  both  feet  of  a  German  woman  of  twenty-two.  It  would  be 
very  confusing  clinically. 

The  secondary  os  calcis  is  very  puzzling,  inasmuch  as  the  term  seems  to  be 
applied  to  two  distinct  structures.  The  most  typical  one  forms  the  very  front 
of  the  sustentaculum  and  is  usually  a  small  bone  with  a  convex  posterior  border 
fitting  accurately  into  a  corresponding  concavity  in  the  front  of  the  susten- 
taculum. The  other  non-typical  form  (which  I  cannot  feel  sure  is  really  the  same 
thing)  is  a  non-articular,  rough,  ill-defined  projection  from  the  front  and  top  of 
the  os  calcis,  pointing  towards,  if  it  does  not  reach,  the  space  between  the  sca- 
phoid, cuboid,  and  the  head  of  the  astragalus.  It  is  apparently  by  an  over- 
development of  this  process  that  the  os  calcis  and  scaphoid  are  occasionally 
2 


18      VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

brought  into  contact.  Once  I  have  seen,  in  a  very  pathological  foot,  what 
looked  like  a  bone  in  this  place  which  earlier  had  been  distinct  but  had  been 
absorbed   into  the   os  calcis. 

The  variations  of  the  os  calcis  are  many  and  striking.1  Probably  one  of 
the  most  significant  is  the  development  and  position  of  the  external  tubercle 
at  the  back.  Always  much  smaller  than  the  internal  one,  it  may  be  just  about 
in  the  same  transverse  plane  with  it  or  decidedly  in  front  of  it.  Sometimes  it  is 
not  to  be  made  out;  at  other  times  it  is  very  prominent.  All  this  must  have  an 
effect  on  the  way  in  which  the  weight  of  the  body  is  transmitted.  The  devel- 
opment of  this  external  tubercle  must  modify  very  sensibly  the  outline  of  the 
posterior  aspect  of  the  foot.  This  bone  also  varies  in  its  curves  in  a  way  not 
easy  to  analyze. 

Scaphoid,  tibiale  externum,  and  secondary  cuboid.  The  scaphoid  varies  a 
good  deal  in  its  shape,  but  the  causes  are  almost  entirely  due  to  the  two  bones 
just  mentioned.  The  tuberosity  of  the  scaphoid  is  not  necessarily  the  same 
thing  as  the  tibiale  externum,  but  may  vary  within  certain  limits.  When  the  pro- 
jection is  very  large,  particularly  when  its  end  is  more  or  less  marked  off  and 
especially  if  it  is  turned  backwards,  we  have  to  do  with  a  tibiale  more  or  less 
perfectly  fused  with  the  tuberosity.  The  tibiale  externum  is  commonly  known 
as  the  sesamoid  in  the  tendon  of  the  tibialis  posticus,  but  it  is  a  true  part  of  the 
skeleton,  being  found  in  many  mammals  and  being  cartilaginous  in  the  second 
month  of  the  embryo.  I  have  seen  it  as  a  separate  cartilage  at  birth.  Fig. 
62  shows  it  in  a  child  of  two  years.  In  about  10  per  cent,  this  is  a  separate  bone, 
generally  closely  connected  with  the  tuberosity  of  the  scaphoid  by  fibro-carti- 
lage  or  fibrous  tissue.  It  may  play  on  it  with  a  true  joint;  but  more  often  the 
articular  cartilage,  even  when  present,  shows  signs  of  degeneration  and  the  two 
apposed  surfaces  tend  to  interlock.  It  is  more  or  less  involved  in  the  tendon  of 
the  posterior  tibial.  It  sometimes  is  quite  free,  having  no  close  connection  with 
the  scaphoid,  but,  as  Pfitzner  has  shown,  it  is  never  inclosed  in  the  tendon.  Its 
relation  to  the  tuberosity  of  the  scaphoid  is  uncertain,  whether  it  persists  as  a 
distinct  element  or  is  consolidated  with  the  latter.  It  may  be  placed  directly 
internal  to  the  tuberosity,  but  more  often  it  is  somewhat  behind  it,  and  some- 
times so  much  so  that  it  seems  to  form  a  link  between  the  tuberosity  of  the 
scaphoid  and  the  front  of  the  sustentaculum  beneath  and  internal  to  the  head  of 
the  astragalus.  When  fused  it  may  stand  straight  out  as  a  projection  from  the 
scaphoid  or  it  may  bend  backwards  as  a  well-defined  hook,  or  it  may  be  so  com- 
pletely fused  that  its  presence  is  inferred  only  by  the  size  of  the  prominence. 
If  it  pleases  any  one  to  say  that  it  is  simply  a  very  large  tuberosity  there  is  no 


1  Consult  Laidlaw,  Journ.  of  Anat.  and  Phys.,  vols,  xxxviii  and  xxxix. 


THE    FOOT— VARIATIONS    AND    ADDITIONAL    BONES  19 

way  of  convincing  him,  nor  does  it  practically  matter.  Pfitzner  has  once  seen 
it  subdivided,  and  in  two  or  three  other  cases  an  imperfect  division  was  indi- 
cated by  furrows.  The  tendency  of  an  independent  tibiale  externum  is  to  be 
symmetrical.  Thus  Pfitzner  found  it  26  times  on  both  sides  and  onlv  17  times 
on  one  side.  He  found  it  nearly  twice  as  often  in  women  as  in  men.  As  to  size, 
the  largest  seen  by  Pfitzner  had  a  chief  diameter  of  19  mm.  He  found  but  five 
under  5  mm.,  showing  that  very  minute  forms  are  rare.  It  is  evident  that  this  mav 
be  mistaken  for  a  fracture.    The  hook-form  is  shown  by  the  X-ray  very  clearly. 

The  secondary  cuboid.  Pfitzner  identified  this  occasional  bone  without 
ever  having  seen  it  separate.  Since  then  Schwalbe  has  once  seen  it  distinct  and 
I  have  a  specimen  in  which  at  an  earlier  period  it  almost  certainly  was  so.  In 
spite  of  its  name  it  is  more  frequently  fused  with  the  scaphoid  than  with  the 
cuboid  and  it  is  considered  in  this  paragraph  only  as  connected  with  the  former. 
Situated  at  the  lower  outer  edge  of  the  scaphoid,  it  gives  that  bone,  when  fused 
with  it,  a  more  or  less  quadrangular  shape.  It  sometimes  is  so  bent  as  to  be 
continued  proximally  into  the  sole  of  the  foot.  I  have  once  seen  an  X-ray  in 
which  it  was  tolerably  clearly  indicated  as  a  circular  disc  in  the  sole.  In  other 
cases,  and  probably  in  most,  it  is  not  much  bent  under  the  sole,  but  attached 
to  the  lower  part  of  the  scaphoid,  giving  it  a  characteristic  four-sided  outline. 
Sometimes  it  touches  the  cuboid  by  a  considerable  border,  thus  bringing  the 
scaphoid  and  cuboid  into  contact.  They  may  be  connected  by  fibro-cartilage. 
The  dorsal  border  of  the  front  of  the  scaphoid  may  be  pretty  nearly  a  contin- 
uous line,  or  it  may  present  one  or  two  points  at  the  interspaces  between  the 
cuneiform  bones.  The  inner  one  of  these  probably  represents  the  inter-cunei- 
form bone  (described  later)  which  I  observed  between  the  proximal  ends  of 
the  internal  and  middle  cuneiforms.  I  strongly  suspect  that  in  course  of  time 
a  similar  bone  will  be  found  between  the  middle  and  outer  cuneiforms  repre- 
sented now  occasionally  by  the  outer  point. 

Hyrtl  described  an  elevation  on  the  dorsum  of  the  scaphoid  very  like  the 
one  above  the  head  of  the  astragalus  which  he  also  named  a  trochlear  process. 
I  have  seen  a  case  very  like  his.  I  believe  it  to  be  pathological;  but,  as  said  of 
the  preceding  instance,  it  is  worth  knowing  that  it  may  be  found  just  in  this 
place  and  that  in  all  probability  is  not  the  result  of  a  lesion. 

Subdivided  internal  cuneiform.  This  very  striking  variation  is  extremely 
rare.  I  have  never  seen  it,  though  I  have  searched  for  it  carefully  for  years. 
In  a  typical  case  the  bone  is  divided  into  a  dorsal  and  a  plantar  half.  I  have 
found  it  in  an  X-ray  of  a  child.  (Figs.  61  and  62.)  A  line  on  the  anterior  sur- 
face hinting  at  a  division  is  very  common. 

The  intercuneiform.  This  is  a  small  wedge-shaped  bone  with  a  dorsal 
triangular  surface  situated  on  the  dorsum  of  the  foot  close  in  front  of  the  sea- 


20      VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 

phoid  separating  the  proximal  parts  of  the  internal  and  middle  cuneiform  bones 
but  apparently  cut  off  from  the  latter  rather  than  from  the  former.  I  am  the 
onlv  one  who  ever  observed  it,  and,  curiously  enough,  have  seen  it  twice.1  I  have 
a  rather  vague  recollection  of  having  seen  it  also  many  years  ago  before  I  knew 
enough  to  appreciate  it.  The  interpretation  of  skiagraphs  of  this  region  of  the 
foot  strikes  me  as  difficult.  I  think  I  have  seen  this  bone  thus  shown  at  least 
once  (whether  quite  distinct  or  partly  fused  with  the  middle  cuneiform  I  can- 
not say),  but  I  do  not  dare  to  feel  sure  of  the  observation. 

The  middle  cuneiform.     Of  this  bone  there  is  nothing  to  say. 

The  external  cuneiform.  There  would  be  nothing  to  say  of  this  bone  were  it 
not  that  the  cat  tribe  especially,  as  well  as  some  others  of  the  carnivora,  have  a 
hook-like  process,  os  unci,  on  the  distal  end  of  the  plantar  surface,  of  which 
Pfitzner  saw  one  instance  in  man.  It  may  have  some  relation  to  the  fusing  of 
this  cuneiform  with  the  third  metatarsal  which  is  considered  later. 

The  cuboid.  Of  this  bone  also  there  would  be  nothing  to  say  were  it  not  for 
the  secondary  cuboid,  an  occasional  bone,  the  relations  of  which  with  the  sca- 
phoid have  been  already  discussed.  It  may  be  found  fused  with  the  cuboid,  pre- 
senting a  well-marked  process  under  the  head  of  the  astragalus,  with  which  it 
may  articulate. 

The  peroneum,  commonly  known  as  the  sesamoid  in  the  tendon  of  the  pero- 
neus  longus,  occurs  in  less  than  10  per  cent.  It  may  be  a  large  bone  nearly  filling 
the  depression  in  the  side  of  the  cuboid  on  which  it  plays,  a  bursa  intervening, 
or  it  may  be  more  closely  in  relation  with  the  calcaneum.  It  may  be  sub- 
divided. The  largest  I  have  seen  measured  before  maceration  nearly  2  cm.  and 
was  more  than  half  as  broad,  but  ossification  had  invaded  the  tendon. 

The  intermetatarseum  is  a  very  interesting  bone,  found  in  some  10  per  cent, 
between  the  internal  cuneiform  and  the  first  and  second  metatarsals.  It  has  been 
called  with  considerable  plausibility  a  part  of  a  ray  which  has  dropped  out  of 
the  plan,  the  bone  representing  the  base  of  a  metatarsal.  Some  representa- 
tives of  a  shaft  have  lately  been  described.2  It  might  perhaps  be  as  well 
accounted  for  as  a  futile  attempt  at  polydactylism.  Gruber  once  found  the 
bone  represented  in  cartilage  at  birth.  The  bone  may  be  free,  or  fused  with  any 
one  of  the  three  neighbours.  In  one  case  it  joined  each  by  an  articular  surface; 
but  it  usually  is  fused  with  one  and  in  contact  with  one  or  both  of  the  others, 
probably  more  often  without  a  true  joint.  It  tends  to  present  a  point  at  the 
distal  end.  What  may  be  called  its  base  rests  usually  on  the  internal  cunei- 
form.    The  most  common  form  in  my  experience  is  to  find  it  fused  with  the 


1  Atvit    Anzeiger,  Bd.  xx,  11)02. 

*Lunghetti,  Aunt.  Anzeiger,  Bd.  xxviii,  1906,  S.  479. 


THE    FOOT— VARIATIONS    AND    ADDITIONAL    BONES  21 

internal  cuneiform  so  that  it  presents  an  elongation  of  the  outer  distal  angle  of 
that  bone  on  the  dorsum,  which  may  be  marked  off  with  various  degrees  of 
clearness.  When  fused  with  the  second  metatarsal  it  projects  forwards  and 
inwards,  having  much  the  look  of  an  exostosis.  I  have  seen  but  two  cases  of 
synostosis  with  the  first  metatarsal.  All  these  forms  are  in  the  Warren  Museum. 
Here  is  a  bone  which  may  be  i  cm.  or  more  in  length  placed  in  an  interspace 
so  that  one  would  expect  it  to  be  a  prominent  feature  in  skiagraphs,  and  one 
which  might  easily  give  rise  to  a  wrong  diagnosis  of  fracture  or  of  exostosis. 
In  point  of  fact  this  region  shows  very  badly  with  the  X-ray,  apparently  owing 
to  a  confusion  of  the  lines  of  the  two  surfaces.  Be  that  as  it  may,  I  do  not  re- 
member to  have  seen  on  plates  a  single  intermetatarseum  which  struck  me  as 
satisfactory. 

The  metatarsals .  The  first  metatarsal  shows  considerable  variation  in  the 
plantar  end  of  the  base  which  may  be  prolonged  and  which  Pfitzner  suspected 
to  contain  an  un described  element.  It  is  doubtful  whether  this  would  have  any 
practical  importance.  It  is  not  uncommon  to  find  a  bursa  and  other  more  or  less 
distinct  signs  of  a  joint  between  the  first  and  second  metatarsals  near  their 
bases.  An  articular  facet  of  hyaline  cartilage  is  found  on  the  first  in  about  25 
per  cent.,  according  to  Gruber.1  I  cannot  remember  ever  having  seen  a  corre- 
sponding true  facet  on  the  second;  but  Gruber  states  that  of  the  feet  having 
this  joint  one  quarter  present  on  the  second  metatarsal  a  facet  of  hyaline  car- 
tilage, one  half  a  coating  of  fibro-cartilage,  and  the  other  quarter  a  thickening 
of  the  periosteum. 

The  Vesalianum,  corresponding  to  the  bone  of  the  same  name  in  the  hand, 
is  the  proximal  and  external  part  of  the  tuberosity  of  the  fifth  metatarsal. 
It  is  excessively  rare.  I  have  never  seen  it  in  the  macerated  foot  of  an  adult. 
Spronck2  has  seen  it  at  birth,  and  I  think  I  have  probably  made  the  same  obser- 
vation.3 I  have  once  seen  it  in  the  skiagraph  of  a  girl  of  twelve.  The  entire 
base  of  the  fifth  metatarsal  varies  very  much  in  size.  The  Vesalianum  is  usually 
more  or  less  marked  off  by  a  groove  on  the  plantar  surface.  Gruber4  has  seen 
a  proximal  epiphysis,  not  to  be  confounded  with  the  Vesalianum,  distinct  in  an 
adult. 

The  phalanges.    Apart  from  minor  variations  in  length,  the  most  important 

1  Memoirs  Acad.  St.  Petersburg,  xvii,  187 1. 
2Anat.  Anzeiger,  Bd.  ii,  1887. 

3  The  bones  had  been  separated  by  Thilo's  method  or  by  a  modification  of  it;  but  as  I 
made  some  slight  use  of  the  scalpel  I  had  an  uneasy  feeling  that  I  might  have  made  a 
cut,  though  I  am  not  aware  of  having  done  so.  I  prefer  to  speak  of  the  observation  as 
doubtful. 

4  Archiv  fur  Anat.  und  Phys.,  1875,  S.  48. 


22  VARIATIONS    OF   THE    BONES   OF   THE    HANDS   AND   FEET 

feature  is  the  occasional  atrophy  of  the  bones  of  the  middle  and  terminal  rows. 
That  of  the  middle  phalanx  of  the  little  toe  is  the  most  marked  and  common. 
It  shall  be  considered  in  the  next  section  treating  of  fusions.  The  middle 
phalanx  may  be  wanting  in  all  the  toes.  The  terminal  phalanx  shows  a  consider- 
able range  of  forms.  It  may  be  small  and  degenerate  especially  in  case  of 
fusion  with  the  middle  phalanx. 

The  sesamoid  bones  which  may  be  found  in  the  metatarso-phalangeal  joints 
and  in  the  joint  proximal  to  the  last  phalanx  are  as  follows:  The  two  under 
the  head  of  the  first  metatarsal  are  constant;  then  there  is  an  interphalangeal 
one  of  the  great  toe,  opposite  the  middle  of  the  plantar  aspect  of  the  joint,  in 

50.6  per  cent.,  a  tibial  one  of  the  second  toe  at  the  metacarpo-phalangeal  joint  in 
1.8  per  cent.,  and  two  in  the  same  joint  of  the  little  toe,  the  tibial  in  5.5  per  cent, 
and  the  fibular  in  6.2  per  cent.  There  is,  moreover,  a  distal  interphalangeal  one 
opposite  the  middle  of  the  joint  of  the  second  toe  in  8  per  cent.  As  just  men- 
tioned, the  first  two  are  constant.    They  are,  moreover,  the  only  ones  present  in 

40.7  per  cent.  The  most  common  combination  is  when  there  is  also  the  distal 
sesamoid  of  the  great  toe.  This  occurs  in  48  per  cent.  No  other  combination  is 
worthy   of  notice.     All  this  is  according  to  Pfitzner. 

Subdivision  of  the  internal  sesamoid  of  the  great  toe  is  not  so  very  uncommon, 
the  division  being  by  a  cross  line  into  a  larger  proximal  and  a  smaller  distal  part. 
I  have  seen  this  several  times  both  in  the  bones  and  in  X-rays,  and  have  seen 
once  the  external  divided  in  the  same  manner  with  the  suspicion  of  a  longi- 
tudinal division  of  the  larger  piece.  Stieda1  found  two  sesamoid  bones  of  the 
plantar  aspect  of  the  interphalangeal  joint  of  the  great  toe  and  at  the  same 
time  a  subdivided  sesamoid  at  the  metacarpo-phalangeal  joint.  The  man  had 
suffered  from  a  previous  injury  to  the  ball  of  the  foot.  He  saw  twice  a  tibial 
sesamoid  of  the  fourth  toe  with  the  X-ray. 

FUSION  OF  BONES  AND  VARIATIONS 
OF  RELATIONS. 

Fusion  of  astragalus  and  os  calcis.  The  abnormal  condition  occurs  at  the 
posterior  end  of  the  sustentaculum  and  may  be  attributed  to  the  os  sustentaculi 
fusing  with  both  bones.  The  bones  may  be  firmly  co-ossified  or  they  may  be 
united  by  gristle,  the  apposed  surfaces  showing  the  characteristic  irregular 
finish.     Either  of  these  conditions  is  decidedly  uncommon. 

Fusion  of  astragalus  and  scaphoid.  There  are  a  very  few  recorded  cases, 
some  of  which  seem  certainly  not  to  be  pathological.    I  have  never  seen  it. 

1  Beitriige  zur  klin.  Chirurgie,    1904. 


FUSION    OF    BONES    AND    VARIATIONS    OF    RELATIONS  23 

The  relations  of  the  scaphoid  to  the  cuboid  and  to  the  os  calcis.  Normally  the 
scaphoid  and  cuboid  are  connected  by  ligament,  but  very  frequently  there  is  a 
true  joint.  Gruber1  found  one  present  in  45.5  per  cent,  of  200  feet.  Pfitzner 
found  an  evident  joint  in  50.4  per  cent,  of  437  feet.  Among  notes  taken  by  me 
several  years  ago  I  find  records  of  the  presence  or  absence  of  this  joint  in  200 
feet  with  the  result  that  it  was  present  in  about  60  per  cent.  A  difficulty  in 
such  statistics  is  that  occasionally  the  joint  is  very  small  or  ill-marked,  suggest- 
ing that  the  bones  have  merely  a  bursa  between  them  instead  of  a  true  joint. 
It  is  to  be  noted  that  Pfitzner  excluded  some  which  he  called  "minimals."  It 
is  distinctly  more  common  in  women  than  in  men,  but  Pfitzner 's  figures  on  this 
point  are  not  large  enough  for  a  true  average.  Fusion  of  these  bones  or  connection 
by  cartilage  is  very  rare.  I  have  seen  bony  connection  once  and  cartilaginous 
once  or  twice.  Pfitzner  has  seen  the  latter  three  times,  twice  in  one  body.  The 
os  calcis  may  project  forward  so  as  to  reach  the  end  of  the  scaphoid,  thereby 
crossing  the  line  of  Chopart's  amputation,  and  may  be  connected  with  it  by  a 
true  joint,  by  synchondrosis,  or  by  synostosis.  Cartilaginous  union  has  been 
seen  at  birth.  The  os  calcis  may  reach  forward  only  far  enough  to  just  touch 
the  scaphoid,  in  which  case  the  latter  lies  against  the  cuboid  as  well;  or  it  may 
go  so  far  forward  as  to  exclude  the  cuboid  from  any  relation  with  the  scaphoid. 
The  question  has  arisen  whether  synchondrosis  of  these  bones  has  any  important 
effect  on  the  shape  of  the  foot.  Holl  believed  it  to  be  a  cause  of  flat  foot.  My 
experience  tallies  exactly  with  Pfitzner's,  who  disagrees  with  this  theory.  We 
both  have  seen  beautifully  shaped  feet  with  high  arches  when  this  arrangement 
exists,  but  we  also  have  seen  some  cases  of  broken-down  foot.  Probably  it  has 
no  effect  one  way  or  the  other. 

Fusion  of  the  middle  and  outer  cuneiform  bones.  One  single  instance  of  this 
was  observed  by  Pfitzner  on  an  odd  foot,  otherwise  normal  and  healthy.  The 
union  was  between  the  plantar  halves  of  the  bones.  The  same  author  had  seen 
this  fusion  in  the  dog  and  the  cat. 

Fusion  of  the  external  cuneiform  and  the  third  metatarsal .  This  by  no 
means  very  rare  variation  has  been  reported  only  by  Pfitzner.  I  have,  how- 
ever, met  with  three  or  four  cases  myself.  It  occurs,  like  the  rest,  at  the 
plantar  surface  and  may  be  by  cartilage  or  bone.  It  is  often  found  on  both 
sides.  Pfitzner  has  seen  it  fourteen  or  fifteen  times.  He  reports  a  case  of 
a  boy  of  seventeen  with  it  on  both  sides,  chiefly  cartilaginous  but  with 
beginning  synostosis.  I  have  seen  a  foot  of  a  girl  of  nineteen,  beautifully 
formed  and  perfectly  normal,  in  which  the  union  is  bony  but  present  only  at  the 
plantar  end  of  the  joint.  Pfitzner  is  inclined  to  ascribe  it  to  an  exceptional 
element,  the  os  unci,  on  the  under  side  of  the  cuneiform. 

1  Arch,  fur  Anat.  Phys.  und  wissen.  Med.,  1871. 


24 


VARIATIONS  OF  THE  BONES  OF  THE  HANDS  AND  FEET 


The  relations  of  the  external  cuneiform  to  the  cuboid  and  to  the  base  of  the 
fourth  metatarsal.  It  is  generally  taught  that  the  line  of  Lisfrane's  amputa- 
tion, external  to  the  irregularity  caused  by  the  shortness  of  the  middle  cunei- 
form, describes  a  continuous  curve;  but,  as  apparently  Lisfranc  himself  knew, 
there  is  very  frequently  an  irregularity  caused  by  the  projection  of  the  external 
cuneiform  beyond  the  cuboid  so  as  to  be  in  relation  with  the  inner  surface  of  the 
base  of  the  fourth  metatarsal,  to  which  it  may  be  connected  by  a  joint. 

The  relations  are  best  shown  by  this  table,  which  I  have  compiled  from  the 
researches  of  Pfitzner  on  438  feet. 

The  projection  of  the  cuneiform  beyond  the  cuboid  is  2mm.  or  less  in  45.7  per  cent. 

3  "  3-2 

4  "  10.3     " 

5  "  18.9     " 
"                "                  "            "                         6  "  11. 9 

7  "  "  7-8     " 

8  "  "  2.1     " 

9  "  .1      " 

Fusion  of  the  cuboid  with  the  fourth  and  fifth  metatarsals.  There  is  no 
record  of  this  ever  having  been  seen  post  mortem.  I  have  seen  it  with  the  X-ray 
in  both  feet  of  a  man  of  about  thirty  suffering  from  pain  at  that  joint  following 
gonorrhoea.     It    was    presumably  pathological. 

Fusion  of  the  middle  and  terminal  phalanges  of  the  fifth  toe  has  been  observed 
by  Pfitzner  in  37  per  cent.  This  fusion,  which  certainly  is  not  pathological,  and 
which  occurs  in  embryos  and  children,  is  due,  as  he  has  shown,  to  the  absorp- 
tion of  the  middle  phalanx  into  the  terminal  one.  Its  frequency  is  easily  verified 
by  the  X-ray.  It  is  to  be  noted  that  the  terminal  phalanges,  besides  the  centre 
for  the  shaft,  and  that  for  the  proximal  epiphysis,  have  also  a  cap-like  ossifica- 
tion which  soon  joins  the  free  end  of  the  terminal  phalanx.  In  cases  of  fusion 
of  the  phalanges  it  seems  that  the  proximal  epiphysis  of  the  middle  phalanx  is 
wanting  (in  fact  I  think  it  generally  is  wanting  in  the  little  toe)  as  is  also  the 
body  of  the  terminal  phalanx.  The  proximal  epiphysis  of  the  latter  is  very 
large  and  is  joined  by  the  cap,  the  centre  of  the  last  phalanx  not  appearing. 
This  compound  piece  then  joins  the  centre  for  the  rudimentary  middle  phalanx. 
The  line  representing  the  distal  end  of  the  middle  phalanx  may  be  seen  on  the 
surface  of  the  bone,  but  both  sections  and  the  X-ray  show  a  perfect  continuity 

mcture. 

Coalescence  of  the  middle  and  terminal  phalanges  occurs  in  other  toes  than 
tin  fifth,  but  more  and  more  rarely  towards  the  inner  side  of  the  foot.  Moreover 
the  progress  inwards  is  perfectly  regular.  Thus  according  to  Pfitzner  the  fourth 
toe  never  shows  it  when  it  is  not  present  in  the  fifth,  nor  the  third  if  it  be  not 


FUSION   OF    BONES    AND    VARIATIONS    OF    RELATIONS  25 

present  in  the  fourth  and  fifth,  nor  the  second  if  it  be  not  present  in  the  three 
beyond  it. 

I  have  often  seen  in  X-rays  of  children's  feet  an  appearance  which  I  am 
rather  at  a  loss  to  explain,  and  of  which  I  find  no  account.  It  seems  as  if  the 
little  toe  had  four  phalanges.  I  can  only  infer  that  the  proximal  epiphysis  of 
the  second  phalanx  is  so  large  as  to  be  mistaken  for  a  phalanx.  I  have 
once  seen  a  strong  suggestion  of  the  same  condition  in  the  skiagraph  of  an 
adult  foot. 


PLATES  SHOWING  THE 
VARIATIONS   OF   THE   BONES 
OF    THE    HANDS    AND    FEET 


PLATE  I. 

Fig.  i.  This  man  has  a  supernumerary  bone,  presumably  the  triangulare. 
The  X-ray  shows  some  pieces  of  stone  which  had  been  driven  into  his  hand  by 
an  explosion.  The  suggestion  that  the  piece  might  be  a  separated  styloid  process 
of  the  ulna  is  not  pertinent,  as  the  styloid  process  is  intact.  It  is  not  impossible, 
however,  that  it  should  have  been  separated  from  the  tip  of  the  styloid  process. 
Pfitzner  figures  a  swelling  on  the  end  of  the  styloid  which  he  considers  a  tri- 
angulare. 

Fig.  2.  A  divided  scaphoid  (without  fracture)  on  the  right  hand  of  440, 
white,  male,  ast.  61.  The  semilunar  has  a  minute  epilunatum  fused  with  it. 
There  is  a  separate  bone,  presumably  an  epipyramis  with  its  long  diameter  (1  cm.) 
placed  transversely  on  the  dorsal  aspect  of  the  cuneiform,  overhanging  the  un- 
ciform. The  opposed  surfaces,  between  it  and  the  cuneiform,  are  rough.  It 
may  be  a  post-mortem  fracture.  Neither  of  these  is  shown  in  the  photograph. 
The  left  hand  shows  a  beautiful  epilunatum  free  (vide  fig.  14).  These  peculiari- 
ties are  insisted  on  as  indicating  a  tendency  to  the  multiplication  of  free  elements 
in  this  body.  The  two  pieces  of  the  scaphoid  were  perfectly  in  place.  It  was 
possible  by  using  considerable  force,  while  holding  the  detached  bone  in  both 
hands,  to  make  the  two  parts  play  very  slightly  on  each  other.  The  line  of 
separation  had  the  characteristic  position  (vide  p.  4).  A  section  showed  the 
pieces  united  by  cartilage.  Dr.  E.  H.  Nichols  was  kind  enough  to  examine  the 
specimen  microscopically  and  reported  that  there  was  no  fracture.  Fig.  8 
shows  the  appearance  of  the  isolated  bone  and  fig.  9  shows  an  X-ray  of  this  bone. 

Fig.  3.  (413,  old  number),  white,  male,  a?t.  74.  This  is  a  divided  scaphoid. 
The  division  may  be  the  result  of  an  error  in  development  or  it  may  be  the  result 
of  a  fracture  of  a  normal  bone.  Assuming  that  the  bone  developed  in  two  pieces 
we  may  say  that  thev  have  not  kept  their  primitive  condition,  like  those  of  the 
preceding  specimen,  but  have  played  one  on  the  other,  to  the  destruction  of  the 
joint,  or  of  the  intervening  cartilage.  It  is  very  possible  that  there  was  both  an 
original  division  of  the  bone  and  also  a  subsequent  lesion.  An  additional  bone 
on  the  dorsum  (just  above  the  arrow)  is  to  be  considered  a  ccntrale. 


PLATE   I. 


PLATE  II. 

Fig.  4.  X-rav  of  a  fracture  of  the  radius  and  a  divided  scaphoid.  I  have 
no  history  of  this  case,  beyond  that  it  is  that  of  an  adult  male  examined  at  the 
hospital  and  diagnosed  as  fracture  of  the  radius  and  of  the  scaphoid.  The  frac- 
ture of  the  former  bone  is  beyond  question;  but  if  any  one  will  contrast  the 
well  defined  border  of  the  cleft  between  the  two  parts  of  the  scaphoid  with  the 
interlocked  edges  of  the  radius  and  will  further  compare  this  line  through  the 
scaphoid  with  that  separating  several  of  the  other  bones  of  the  wrist  he  will  see 
that  there  is  no  evidence  of  a  fracture.  The  diagnosis  was  probably  made  on  the 
assumption  that  if  the  scaphoid  be  found  in  two  pieces  it  must  be  in  consequence 
of  an  injury. 

Fig.  5.  X-ray  of  a  scaphoid  in  two  pieces.  This  is  either  a  fracture  or  an 
instance  of  a  divided  scaphoid,  the  pieces  of  which  have  worked  apart  through 
a  degenerative  process.  Very  probably  this  condition  was  accelerated  or  ini- 
tiated by  a  lesion  occurring  to  a  divided  scaphoid,  but  the  question  cannot  be 
decided. 


PLATE   II. 


PLATE  III. 

Fig.  6.  An  X-ray  of  five  left  and  two  right  scaphoids  imbedded  in  sand, 
the  hands  being  in  the  prone  position.  They  should  have  been  placed  some- 
what more  longitudinally  than  has  been  done.  They  show  a  good  deal  of  varia- 
tion in  structure,  the  two  right  ones  especially  having  a  large  cavity  near  the 
middle. 

Fig.  7.  Four  right  and  two  left  scaphoids  seen  from  the  distal  and  the 
ulnar  side.  The  top  one  shows  a  fused  centrale  partly  marked  off.  The  same 
interpretation  may  be  given  to  the  point  on  each  of  the  lower  pair.  The  right 
one  of  the  upper  pair  has  a  large  cavity  near  the  middle  which  must  be  a  weak 
point.  The  lowest  one  has  a  line  of  nutrient  foramina  suggesting  the  place 
of  union  between  the  two  original  parts.  This  group  shows  very  marked  differ- 
ences in  shape  which  must  be  remembered  in  studying  X-rays. 

Fig.  8.  Drawings  of  the  scaphoid  of  the  hand  shown  in  fig.  2.  The  upper 
one  shows  the  proximal  and  the  lower  the  distal  aspect. 

Fig.  9.  An  X-ray  of  the  same  bone. 

Fig.   10.  Two  d.fferent  types  of  internal  structure  of  scaphoid. 


PLATE  III. 


■/* 


1       • 


PLATE  IV. 

Fig.  ii.  An  X-ray  of  a  young  woman's  hand  showing  a  dark  spot  distal 
to  the  scaphoid,  which  might  perhaps  be  interpreted  as  a  centrale  a  little  out  of 
place.  The  more  I  have  studied  this  photograph  the  more  doubtful  I  have 
become  of  the  correctness  of  this  interpretation,  but  I  have  allowed  it  to  stay  as 
an  instance  of  the  difficulty  of  the  study. 

Fig.  12.  X-ray  of  a  male  hand  showing  a  cavity  that  should  have  been 
occupied  by  the  centrale.  In  this  case  the  bone  may  have  completely  disappeared 
during  development  or  it  may  have  remained  cartilaginous.  This  is  an  uncom- 
monly fine  specimen  of  a  tolerably  common  condition.  It  is  to  be  noted  that 
the  hand  is  not  at  all  turned  to  the  ulnar  side,  under  which  circumstances  more 
or  less  of  a  space  generally  appears  at  this  point. 


PLATE   IV. 


PLATE  V. 

Fig.  13.  Radiale  externum.  C.  120,  white,  male,  set.  70.  Left  hand. 
This  separate  bone  forming  the  tip  of  the  scaphoid  on  the  palmar  aspect  is  13 
mm.  long.  It  rested  on  the  scaphoid  by  a  nearly  smooth  surface  which  prob- 
ably had  once  been  covered  by  non-articular  cartilage.  There  was  no  sign  of 
fracture.  The  distal  surface  of  the  radiale  externum  helped  to  support  the 
trapezium  and  apparently  had  been  covered  by  articular  cartilage.  The  some- 
what pathological  aspect  which  the  bone  presents  was  not  evident  before  com- 
plete maceration.      The  right  hand  was  not  available. 

Fig.  14.  An  epilunatum  free.  440,  white,  male,  set.  61,  the  same  whose 
right  hand  presented  a  divided  scaphoid,  shown  in  fig.  2.  There  is  no  sign  of 
violence  in  this  hand.  The  epilunatum  is  typically  placed  in  the  angle  between 
the  semilunar,  scaphoid  and  os  magnum,  resting  on  the  dorsum  of  the  last. 
The  greatest  diameter  nearly  transverse  is  6.5  mm.  If  this  hand  were  X-rayed 
in  the  usual  position  of  pronation  it  is  unlikely  that  the  outlines  of  this  little 
bone  would  be  recognized. 


PLATE  V. 


PLATE  VI. 

Fig.  15.  Divided  semilunar.  C.  109,  male,  white,  aet.  74.  This  is  an  ex- 
tremely puzzling  case.  There  is  a  free  bone  on  the  dorsum  representing  prob- 
ably more  than  a  third  of  the  semilunar.  On  the  palmar  side  there  is  a  well- 
marked  hypolunatum  fused  with  the  semilunar.  Two  hypotheses  present 
themselves:  either  there  is  a  very  large  epilunatum,  quite  out  of  proportion  to 
what  is  usually  seen,  or  the  bone  is  divided;  and  again  this  may  have  hap- 
pened by  an  error  in  development  or  by  violence.  An  interesting  fact  is  that 
this  is  not  an  unique  observation.  Pfitzner  inclined  to  attribute  a  similar  con- 
dition to  a  fracture.  This  bone  was  coated  with  articular  cartilage  on  its  palmar 
side  which  played  on  the  head  of  the  os  magnum.  Its  distal  face  which  lies 
against  the  semilunar  was  probably  connected  with  it  by  non-articular  carti- 
lage. On  its  ulnar  side  there  was  a  true  joint  between  it  and  the  unciform. 
The  latter  rises  at  its  distal  end  well  above  the  level  of  the  os  magnum,  so  that 
this  separate  bone  forms  the  central  part  of  a  bridge  between  the  unciform  and 
scaphoid  above  the  magnum.  This  elevation  has  a  rather  pathological  aspect, 
though  the  line  of  the  joint  seems  normal.  It  is  noteworthy  that  there  is  the 
opening  on  the  dorsum  of  the  scaphoid  of  a  very  large  cavity  in  that  bone.  The 
other  hand  presented  nothing  noteworthy.  I  inclne  to  think  it  an  unusually 
large  epilunatum  which  developed  separately.  The  coating  of  articular  carti- 
lage on  its  palmar  side  and  on  that  against  the  unciform  do  no  agree  with  the 
theory  of  a  fracture. 

Fig.  16.  Three  semilunar  bones.  The  two  on  the  left  have  each  a  fused 
epilunatum.  The  one  on  the  right  presents  a  large  cavity,  probably  connected 
with  the  entrance  and  exit  of  nutrient  vessels.  The  occurrence  of  this  cavity, 
which  is  occasionally  observed,  might  in  some  cases  account  for  such  a  division 
of  the  bone  as  occurs  in  fig.  15.  In  that  instance,  however,  there  was  no  sign 
of  it. 

Fig.  17.  Ulnare  externum.  H.  175,  white,  male,  set.  63.  This  bone  on  the 
ulnar  side  of  the  wrist  is  one  of  the  rarer  occasional  ones.  I  have  never  recog- 
nized it  in  a  skiagraph,  but  one  would  expect  it  to  show  clearly.  The  specimen 
in  this  figure  is  a  rather  uncommonly  large  one.  It  appears  sometimes  as  a 
knob  on  the  cuneiform  or  unciform  and  might  under  these  circumstances  be 
seen  in  an  X-ray.  This  hand  has  also  a  large  epilunatum  fused  with  the 
semilunar. 


PLATE   VI. 


- 


PLATE  VII. 

Fig.  18.  Secondary  pisiform,  probably  lost.  416,  white,  female,  set.  57. 
Left  hand.  Right  hand  normal.  I  believe  that  this  bone  has  never  been  found 
distinct.  The  hand  is  a  delicate  and  well  shaped  one,  showing  nothing  patho- 
logical nor  unusual  excepting  a  surface  on  the  dorsal  proximal  side  of  the  pisi- 
form which  has  the  appearance  of  having  had  another  bone  connected  with  it 
by  non-articular  cartilage.  Of  course  such  a  specimen  is  not  conclusive  but  it 
is  very  suggestive.  Such  a  bone  should  be  seen  in  a  skiagraph  from  the  ulnar 
side. 

Fig.  19.  This  is  a  pisiform  with  a  fused  secondary  pisiform,  the  element 
thought  to  have  been  lost  in  the  specimen  presented  in  fig.  18.  It  is  a  bone 
of  the  right  hand  seen  from  the  median  side  with  the  hand  supine  and  pointing 
to  the  left. 

Fig.  20.  Proetrapezium.  587,  white,  male,  aet.  75.  The  right  hand  has  a 
free  prcetrapezium  with  articular  cartilage  between  it  and  the  trapezium.  On 
the  dorsum  of  the  same  hand  there  is  an  evident  centrale  fused  with  the  scaphoid. 
The  left  hand  has  a  divided  scaphoid  with  much  wearing  away  of  one  piece.  The 
tendency  to  additional  elements  in  this  individual  is  shown  by  the  persistence 
of  the  praetrapezium  and  centrale. 


PLATE  VII. 


PLATE  VIII. 

Fig.  21.  Subcapitatum  distinct.  746,  white,  male," set.  54.  This  bone,  as 
is  pointed  out  in  the  general  section,  had  been  predicted  by  Pfitzner  and  was 
found  by  the  author  after  Pfitzner's  death.  It  is  an  unique  observation.  The 
bone  is  present  on  both  sides.  There  is  (at  least  in  one,  and  the  description  of 
the  other  is  defective)  a  concave  articular  surface  for  the  magnum  and  another 
for  the  third  metacarpal.  It  is  not  likely  that  this  bone  is  of  any  clinical 
importance,  as,  though  the  prominence  might  be  detected  by  the  X-ray,  there 
is  no  way  of  knowing  whether  it  is  distinct  or  not. 

Fig.  22.  Separate  hamular  process.  H.  386,  white,  male,  aet.  52.  Right 
hand.  The  overhanging  part  of  the  hamular  process  is  distinct.  There  is  no 
sign  of  violence  nor  of  disease.  The  left  hand  is  normal.  Probably  this  could 
be  detected  by  a  skiagraph  with  the  ulnar  side  of  the  hand  against  the  plate. 

Fig.  23.  A  series  of  unciform  bones  showing  variously  developed  hamular 
processes. 


PLATE  VIII. 


Fig.  21 


Fig. 


Fig.  2- 


PLATE  IX. 

Fig.  24.  Styloid  free.  272,  white,  male,  aet.  48.  It  is  worth  noting  that 
the  left  hand  shows  a  furrow  across  the  concavity  of  the  scaphoid,  thus  showing 
a  tendency  in  the  body  to  the  separate  growth  of  elements. 

Fig.  25.  A  separate  styloid  in  an  X-ray.  This  shows  quite  as  well  as  can 
be  expected,  when,  as  is  usual,  skiagraphs  are  taken  with  the  palm  against  the 
plate.  The  only  clinical  application  is  that  this  should  not  be  mistaken  for  a 
fracture.  In  doubtful  cases  the  skiagraphs  should  be  taken  with  the  dorsum 
down. 


PLATE  IX. 


'v 


PLATE  X. 

Fig.  26.  Styloid  fused  with  trapezoid.  591,  white,  female,  aet.  42.  Both 
hands  are  practically  alike.  This  condition  is  much  the  rarest  of  the  possible 
combinations  of  the  styloid.  The  conjoined  trapezoid  and  styloid  is  very  long 
transversely.  It  nearly  conceals  the  ulnar  prominence  of  the  base  of  the  second 
metacarpal  known  as  the  parastyloid. 

Fig.  27.  Styloid  fused  with  os  magnum.  H.  278,  white,  male,  aet.  29.  The 
styloid  of  the  right  hand  is  fused  with  the  os  magnum,  making  the  distal  border 
of  the  latter  approximately  transverse.  Such  a  condition  should  be  recog- 
nized on  an  X-ray  plate.  The  styloid  of  the  left  hand  appears  as  a  very  large 
process  of  the  third  metacarpal.    A  good  instance  of  this  is  seen  in  fig.  28. 


PLATE  X. 


PLATE  XI. 

Fig.  28.  Fusion  of  semilunar  and  cuneiform.  H.  230,  black,  female;  dor- 
sal view.  The  condition  of  the  other  hand  is  unknown.  There  is  a  deep  fissure 
on  the  distal  surface  extending  into  the  palmar  aspect. 

Fig.  29.  Ditto.  H.  358,  black,  male,  aet.  23.  Left  hand,  palmar  view. 
The  fissure  in  the  distal  aspect,  though  deep  in  the  middle,  stops  short  of  the 
borders. 

This  condition,  which  is  found  most  frequently  among  blacks,  should  be 
clearly  shown  by  the  X-ray. 


PLATE  XI. 


PLATE  XII. 

Fig.  30.  Distinct  epiphysis  of  proximal  end  of  the  second  metacarpal. 
X-rav  from  a  young  person  of  15.  There  is  much  uncertainty  whether  this  is 
what  is  called  a  false  epiphysis  or  a  true  one,  or  whether  there  is  any  sharp 
distinction  between  the  two.  What  is  remarkable  is  the  tendency  of  this  con- 
dition to  present  itself  in  this  particular  bone.  In  another  year  it  would  have 
fused  with  the  shaft.  There  is  a  suggestion  of  a  distal  epiphysis  on  the  first 
metacarpal. 

Fig.  31.  Fusion  of  trapezoid  and  second  metacarpal.  Left  hand.  Origin 
unknown.  Surely  female.  The  fusion  extends  through  the  whole  thickness. 
Pfitzner  had  seen  no  true  fusion  and  the  "coalescence"  he  observed  was  limited 
to  the  dorsum. 


PLATE   XII. 


, 


PLATE  XIII. 

Fig.  32.  Fusion  of  fourth  and  fifth  metacarpals.  An  X-ray  from  the 
hand  of  a  boy  of  18.  Both  hands  were  practically  alike.  Note  the  absence  of 
the  distal  half  of  the  fifth  metacarpal. 

Fig.  33.  Ditto,  only  with  very  slight  shortening  of  the  fifth  metacarpal. 
H.  265,  white,  male,  aet.  26.  Right  hand.  Nothing  else  is  abnormal,  but  the 
hand  is  remarkably  small.  The  articulated  bones  measure  only  16.3  cm.  The 
left  hand  and  right  foot  were  not  examined.  Nothing  analogous  was  found  in 
the  left  foot. 


PLATE  XIII. 


PLATE  XIV. 

Fig.  34.  Trigonum  single  on  left,  double  on  right.  C.  112,  white,  male, 
set.  30.  These  are  very  large  and  very  healthy  feet  from  a  man  in  the  prime 
of  life.  There  is  no  sign  of  lesion  nor  of  disease.  The  left  foot  has  a  trigonum 
connected  to  the  posterior  process  by  cartilage.  On  the  right  the  trigonum  is 
double.  Both  pieces  have  the  inferior  surface  covered  by  articular  cartilage. 
They  were  joined  by  synchondrosis,  the  much  larger  internal  piece  overlapping 
the  other.  The  larger  piece  was  attached  to  the  astragalus  by  a  cartilaginous 
surface,  the  smaller  apparently  partly  in  the  same  way  and  partly  by  ligament. 
It  is  worth  noting  that  the  left  hand  of  this  body  had  a  free  styloid. 


PLATE  XIV. 


Fig.  34- 


PLATE   XV. 

Fig.  35.  Trigonum  at  end  of  long  process.  629,  female,  white,  set.  40. 
The  under  side  of  the  trigonum  is  beyond  the  articular  portion  of  the  process. 
There  are  no  notes  taken  at  the  time  of  dissection,  but  the  connection  with  the 
astragalus  must  evidently  have  been  by  cartilage  or  ligament.  The  bones  show 
roughnesses  at  several  points  on  the  dorsum.  There  is  no  reason  to  believe  this 
bone  was  the  result  of  a  fracture,  but  the  possibilities  of  its  being  of  pathologi- 
cal origin  may  perhaps  be  admitted.  The  lower  arrow  points  at  the  normal 
relation  of  the  outer  end  of  the  scaphoid  in  contradistinction  to  its  synchon- 
drosis with  the  os  calcis  shown  in  fig.  36. 

Fig.  36.  Trigonum.  C.  122,  white,  male,  aet.  30.  Left  foot.  The  feet  are 
healthy  but  present  several  peculiarities.  This  side  view  is  given  for  conven- 
ience of  comparisons  with  X-rays.  The  trigonum  is  connected  by  cartilage. 
The  process  is  well  developed  on  the  other  foot.  This  foot  presents  also  a  syn- 
chondrosis between  the  os  calcis  and  the  scaphoid,  and  fusion  of  the  second  and 
third  phalanges  of  the  little  toe.  There  was  also  a  free  intermetatarseum  about 
3  mm.  in  length  which  was  lost.  The  right  foot  had  a  much  broader  synchon- 
drosis between  the  os  calcis  and  scaphoid,  a  very  minute  nodule  in  areolar 
tissue  representing  the  intermetatarseum,  and  a  normal  little  toe. 


PLATE   XV. 


Fig.  35. 


Fig.  36. 


PLATE  XVI. 

Fig.  37.  Trigonum  shown  by  the  X-ray  taken  of  a  leg  amputated  for  chronic 
disease  higher  up,  with  no  question  of  lesion  of  the  foot. 

Fig.  38.  Fused  trigona  in  both  feet.  H.  313,  white,  male,  aet.  29.  The 
larger  trigonum  on  the  left  astragalus  is  almost  free,  that  of  the  right  is  almost 
assimilated.    There  is  no  suggestion  of  injury. 


PLATE  XVI. 


Fig    37. 


Fig.  38. 


PLATE  XVII. 

Fig.  39.  Large  internal  process  of  astragalus.  H.  317,  white,  male,  set.  51. 
This  is  an  exaggerated  and  hook-like  internal  tubercle.  There  is  a  furrow  vis- 
ible on  the  internal  aspect  as  if  separating  it.  The  left  foot  presents  no  such 
peculiarity.  A  practical  question  is  whether  it  would  be  possible  to  distinguish 
it  by  the  X-ray  from  a  trigonum.  Possibly  this  might  be  done  by  taking  a  view 
of  the  foot  from  both  sides. 

Fig.  40.  Trochlear  process  near  head  of  astragalus.  H.  211,  white,  male. 
Right  foot.  Left  foot  not  examined.  Though  a  priori  one  is  inclined  to  call 
this  process  pathological,  it  does  not  present  any  roughness  nor  is  there  any  sign 
of  disease  in  the  other  bones.  In  another  foot  of  unknown  origin  the  process  has 
a  somewhat  pathological  appearance  but,  except  for  a  tendency  to  flatness,  the 
foot  is  otherwise  healthy.    This  process  shows  very  well  in  skiagraph. 


PLATE  XVII. 


Fig.  39. 


Fig 


G.    40. 


PLATE  XVIII. 

Fig.  41.  Three  astragali  showing  varying  angle  of  inclination  of  the  long 
axis  of  the  head. 

Fig.  42.   Five  astragali  showing  varying  angle  of  lateral  inclination  of  the 
neck. 

Fig.  43.  Five  astragali  showing  varying  development  of  external  posterior 
process. 


PLATE  XVIII. 


Fig.  41. 


Fig.  42. 


Fig.  43. 


PLATE  XIX. 

Fig.  44.  Immense  peroneal  process  of  os  calcis.  C.  117,  black  or  mulatto, 
male,  not  past  middle  age.  The  process  is  very  large  on  both  feet,  but  some- 
what larger  on  the  left,  where  the  upper  aspect  presents  a  flat,  smooth  facet  on  its 
outer  border.  The  shape  of  the  os  calcis  approaches  that  of  the  chimpanzee. 
Pfitzner  figures  a  somewhat  similar  bone  from  the  body  of  a  young  German 
woman.  It  is  extermely  rare.  In  both  feet  of  this  negro  there  is  a  large  tibiale 
externum  fused  with  the  scaphoid  and  a  trigonum  so  thoroughly  fused  as  to  be 
hard  to  recognize. 


PLATE  XIX. 


Fig.  44. 


PLATE  XX. 

Fig.  45.  Probably  pathological  development  of  the  peroneal  process  of  the 
os  calcis.  C  85,  white,  male,  get.  62.  Probably  this  overhanging  curved  plate  of 
bone  is  for  the  most  part  due  to  ossification  of  fibrous  tissue.  In  other  places, 
however,  the  foot  shows  few  signs  of  a  similar  condition.  The  left  foot  was  not 
observed.  This  foot  is,  of  course,  radically  different  from  the  preceding  one  in 
which  the  process  is  not  only  larger,  but  thick  and  massive.  It  may  be  ques- 
tioned, however,  whether  one  form  would  be  distinguished  readily  from  the 
other  in  a  skiagraph. 

Fig.  46.  Five  calcanea  showing  from  behind  different  inclinations  of  the 
bone  and  varying  development  of  the  plantar  tubercles. 

Fig.  47.  Five  calcanea  (not  the  same  as  the  preceding)  showing  on  the 
plantar  side  the  varying  shape  and  development  of  the  plantar  tubercles. 


PLATE   XX. 


Fig.  45. 


Fig.  46. 


4 

^| 

W^  "■'           Wm      ' 

K«k^  . 

^? 

Vr»>(                  M 

^Kk..                               ^^^^^-'' 

/■ 

*'<   ' J 

A' 

^3 

^H 

H                                '  Hi 

bbV  ^H 

B       9  Bx  ■" 

m»:  ' 

W 
■ 

'  Bl       bi 

^^BI 

Fig.  47. 


PLATE  XXI. 

Fig.  48.  Synchondrosis  of  os  calcis  and  scaphoid.  C.  122,  white,  male.  This 
is  the  mate  of  the  foot  presented  in  fig.  36,  which  showed  a  narrow  strip  of  syn- 
chondrosis between  the  os  calcis  and  the  scaphoid.  On  this  side  it  is  much 
broader,  measuring  about  1  cm.  at  the  dorsum,  which  is  as  broad  as  it  is  often 
found.     The  os  calcis  shows  also  a  rather  large  peroneal  process. 

Fig.  49.  Ditto.  C.  160,  white,  male,  aet.  22.  The  skiagraph  was  taken 
when  the  foot  had  been  only  superficially  dissected. 


PLATE  XXI. 


Fig.  48. 


Fig.  49. 


PLATE  XXII. 

Fig.  50.  Secondary  os  calcis.  These  skiagraphs  are  those  of  a  woman  who 
hurt  her  left  foot  falling  from  the  edge  of  the  bath-tub.  The  diagnosis  of  frac- 
ture was  made  after  that  of  the  left  foot  had  been  taken,  especially  as  there  was 
tenderness  in  the  dorsum  over  the  point  in  question.  A  skiagraph  of  the  right 
foot  showed,  however,  that  there  was  an  extra  bone  at  this  point  in  both  feet. 
The  left  foot  is  at  the  reader's  right. 


PLATE  XXII. 


PLATE  XXIII. 

Fig.  51.  Secondary  os  calcis.  226,  white,  male.  The  small  nodule  is  shown 
in  the  plate.  Unfortunately  the  way  in  which  it  is  connected  with  the  bone 
below  it,  whether  by  joint,  cartilage  or  ligament,  is  not  noted.  It  was  not 
found  in  the  left  foot.  It  is  very  common  in  skiagraphs  of  the  outer  side  of  the 
foot  to  see  a  projection  of  the  os  calcis  in  this  direction,  which  if  marked  would 
go  on  to  join  the  scaphoid.  It  is  very  difficult  to  determine  how  much  of  this 
effect  is  due  to  bone  and  how  much  to  the  position  of  the  plate.  In  this  foot  the 
plantar  end  of  the  third  cuneiform  was  united  to  the  matatarsal  by  synchon- 
drosis.    Another  form  of  secondary  os  calcis  is  shown  in  fig.  64. 

Fig.  52.  Tibiale  externum.  This  foot  is  surely  male,  but  its  origin  is  un- 
known. A  large  tibiale  is  placed  between  the  scaphoid  and  the  sustentaculum. 
It  evidently  was  joined  to  the  former  by  synchondrosis.  The  same  foot  has  a 
good  specimen  of  an  inter metatarseum  fused  with  the  internal  cuneiform. 


PLATE  XXIII. 


PLATE  XXIV 

Fig.  53.  Ditto.  640,  white,  male,  ast.  45.  The  tubercle  of  the  scaphoid  is 
so  large  and  projecting  in  this  case  that  it  might  very  well  pass  for  a  fused  tibiale 
externum,  but  it  bears  a  small  bone  projecting  from  it  outward  and  backward. 
There  seems  to  be  a  special  facet  for  it;  but  whether  it  was  joined  to  the  sca- 
phoid bv  cartilage  or  glided  on  it  in  the  tendon  of  the  posterior  tibial  must 
remain  uncertain. 

Fig.  54.  Ditto.  H.  252,  female,  white.  The  tibiale  externum  is  fused  to 
the  back  of  the  tubercle  of  the  scaphoid  so  as  to  form  a  hook. 


PLATE   XXIV. 


PLATE  XXV. 

Fig.   55.  X-ray  of  tibiale  externum  in  the  style  of  that  shown  in  fig.  52. 
Fig.   56.  Ditto  of  one  resembling  that  shown  in  fig.  54. 


PLATE   XXV. 


PLATE  XXVI. 

Fig.  57.  Secondary  cuboid  fused  with  scaphoid.  Origin  unknown,  but 
surelv  male.  It  is  highly  probable  that  this  bone  was  once  free  and  became 
fused  with  the  scaphoid  in  later  life.  The  dorsal  aspect  of  the  foot,  particu- 
larly of  the  scaphoid,  is  pathological,  but  the  sole  may  be  called  healthy.  The 
upper  part  of  this  bone  was  cartilage-coated,  forming  a  part  of  the  socket  for  the 
head  of  the  astragalus.  It  would  seem  as  if  so  strong  a  bone  should  be  recognized 
by  the  X-ray. 

Fig.  58.  Ditto.  The  origin  of  the  specimen  is  unknown,  but  the  bone  is 
unmistakable  though  not  so  clearly  marked  off  from  the  scaphoid  as  the  preced- 
ing one.  It  is  more  vertically  placed,  bending  but  very  slightly  under  the  head 
of  the  astragalus.  It  is  more  striking  than  any  in  the  following  figure.  (Fig. 
65  should  be  studied  in  this  connection.) 


PLATE  XXVI. 


PLATE  XXVII. 

Fig.   59.   Five  scaphoids  showing  the  varying  development  of  the  secondary 
cuboid,  which  is  absent  in  the  first  bone  and  strong  in  the  last. 

Fig.  60.   Five  scaphoids  showing  the  varying  development  of  the  tibiale 
externum  which  is  small  or  wanting  in  the  first  and  large  in  the  last. 


PLATE  XXVII. 


Fig.  59. 


Fig.  60. 


PLATE  XXVIII. 

Fig.  6i.  Divided  internal  cuneiform.  This  X-ray  is  that  of  a  foot  of  a 
little  girl  of  two  years.  The  study  of  the  plate  and  the  next  one  shows  an  extra 
bone  among  the  cuneiforms  which  can  be  explained  only  as  a  division  of  the 
internal  one.  There  was  no  history  of  injury,  but  the  foot  had  been  sore  for 
about  a  month  when  X-rayed  at  the  hospital. 

Fig.  62.  Side  view  of  the  same,  showing  also  ossification  beginning  in  a 
tibiale  externum. 


PLATE  XXVIII. 


u 


Fig.  6i. 


Fig.  62. 


PLATE  XXIX. 

Fig.  63.  Intercuneiform.  White,  male,  ast.  54.  This  figure  and  the  next 
(which  have  appeared  in  the  Anatomischer  Anzeiger)  represent  the  only  instances 
of  this  bone. 

Fig.  64.  Ditto.  White,  male,  aet.  60.  Skiagraphs  often  suggest  an  inter- 
cuneiform, but  the  outlines  of  the  bones,  owing  to  the  arch  of  the  foot,  are  so 
complex  in  this  region  that  there  is  great  danger  of  error.  I  have  never  seen  one 
in  an  X-rav  which  I  dared  to  accept.  This  foot  shows  also  a  secondary  os  calcis 
of  a  different  type  from  that  shown  in  fig.  51. 


PLATE  XXIX. 


PLATE  XXX. 

Fig.  65.  Synchondrosis  of  scaphoid  and  cuboid.  522,  white,  male.  On  the 
plantar  aspect  the  scaphoid  considerably  overlaps  the  cuboid  by  a  projection 
which  very  probably  is  the  secondary  cuboid  fused  with  the  scaphoid.  The 
inferior  part  of  the  opposed  surfaces  has  the  characteristic  appearance  of  one 
joined  to  non-articular  cartilage.  (This  foot  has  also  an  intermetatarseum  fused 
with  the  first  metatarsal.) 

Fig.  66.  X-ray  of  the  peroneum,  commonly  known  as  the  sesamoid  in  the 
tendon  of  the  peroneus  longus. 


PLATE  XXX. 


PLATE  XXXI. 

Fig.  67.  Peroneum.  540,  white,  male,  age  unknown  but  probably  advanced. 
The  peroneum  is  remarkably  large,  being  very  nearly  2  cm.  in  length  and  more 
than  half  as  broad.  A  part  of  its  size,  however,  is  due  to  the  extension  of  ossifi- 
cation from  its  convex  surface  into  the  fibrous  tissue. 

Fig.   68.  Ditto.    An  X-ray  of  the  preceding  foot  taken  before  dissection. 


PLATE  XXXI. 


Fig.  67. 


Fig.  68. 


PLATE  XXXII. 

Fig.  69.  Intermetatarseum.  424,  white,  female,  set.  66.  The  bone  is  free 
in  both  feet,  which  are  practically  similar.  The  bone  of  the  left  foot  has  three 
true  articular  surfaces  for  the  internal  cuneiform,  the  first  and  second  meta- 
tarsals respectively.  On  the  bone  of  the  right  foot  the  surface  for  the  second 
metatarsal  may  not  present  true  articular  cartilage,  but  rather  the  imitation  of 
it,  so  to  speak,  which  is  found  against  a  bursa. 


PLATE  XXXII. 


Fig.  69. 


PLATE  XXXIII. 

Fig.  70.  Ditto.  Male  foot  of  unknown  origin;  the  same  that  appears  in 
fig.  52.  The  intermetatarseum  is  fused  with  the  internal  cuneiform.  This  is  the 
most  common  condition  of  this  -  occasional  bone.  This  foot  has  also  a  free 
tibiale  externum  and  a  secondary  os  calcis  fused  with  the  main  bone. 

Fig.  71.  Ditto.  Female  foot  of  unknown  origin.  The  intermetatarseum  is 
fused  with  the  second  metatarsal .  There  is  a  remarkable  resemblance  between 
different  specimens  of  this  condition.  The  bone  almost  always  has  a  patho- 
logical look  and  suggests  an  exostosis.  In  this  case,  however,  the  foot  as  a  whole 
is  in  quite  as  healthy  a  condition  as  is  commonly  seen. 


PLATE  XXXIII. 


PLATE  XXXIV. 

Fig.  72.  Ditto.  522,  male,  white.  Intermetatarseum  fused  with  the  first 
metatarsal  on  the  left  foot.  The  bone  projects  proximally  from  the  dorsum  of 
the  metatarsal,  articulating  with  a  special  facet  on  the  internal  cuneiform  and 
touching  no  other  bone.  The  articular  surface  on  this  bone  is  separated  by  a  cleft 
from  that  of  the  base  of  the  metatarsal.  This  is  the  rarest  condition  of  this 
bone,  and  this  specimen  the  only  one  which  I  have  seen.  On  the  right  foot  of 
this  body  the  bone  was  fused  with  the  internal  cuneiform.  This  foot  appears  in 
hg-  65. 

These  four  figures  show  all  the  possible  combinations  of  this  bone.  I  have 
seen  it  once  in  an  X-ray,  but  was  not  sure  of  it  at  the  time.  It  was  found  on  the 
foot  when  it  was  subsequently  prepared.  The  lines  of  a  skiagraph  are  very  con- 
fusing in  this  region. 

Fig.  73.  Fusion  of  the  external  cuneiform  with  the  third  metatarsal .  601 
(old  number),  white,  female,  aet.  19.  This  was  the  age  given,  but  it  was  thought 
that  the  body  was  of  a  person  some  years  older.  Be  this  as  it  may,  synchondrosis 
and  beginning  synostosis  were  observed  by  Pfitzner  at  the  age  of  seventeen. 
This  instance  is  a  perfectly  typical  one.  The  foot  is  absolutely  healthy  and  the 
fusion  is  only  at  the  plantar  end  of  the  joint.  This  condition  would  not  be  easy 
to  recognize  by  the  X-ray. 


PLATE  XXXIV. 


PLATE  XXXV. 

Fig.  74.  Varying  development  of  the  tuberosity  of  the  fifth  metatarsal 
and  of  the  Vesalianum.  The  latter  is  very  evident  on  the  bone  on  the  left,  and 
presumably  not  present  on  the  bone  on  the  right. 

Fig.  75.  Vesalianum.  An  X-ray  of  the  foot  of  a  girl  (?)  aged  13,  showing  a 
separate  element  very  clearly.  There  is  no  suspicion  of  injury,  for  the  skia- 
graph was  taken  on  account  of  a  bullet  wound  in  another  part  of  the  foot.  I 
have  placed  a  question  mark  after  the  word  "  girl"  because  my  record  of  the 
sex  is  lost,  but  there  is  very  little  doubt  on  the  point. 


Fig.  74. 


Fig.    75. 


PLATE  XXXVI. 

Fig.  76.  Divided  internal  sesamoid  of  great  toe.  An  X-ray  of  a  woman 
who  applied  at  the  Massachusetts  General  Hospital  for  lung  disease.  She  had 
had  pain  in  her  foot  for  five  years,  but  it  had  grown  worse  six  or  seven  months 
before.  There  were  tenderness  and  grating  about  the  head  of  the  fourth  meta- 
tarsal. There  was  no  allusion  to  symptoms  about  the  great  toe.  There  is  no 
reason  to  doubt  that  the  condition  was  congenital,  especially  as  the  appear- 
ance is  the  typical  one  and  is  by  no  means  excessively  rare. 

Fig.  77.  An  X-ray  of  a  foot  with  fusion  of  the  last  two  phalanges  of  the 
little  toe.  The  same  condition  is  found  in  the  foot  shown  in  fig.  36.  There  is  no 
reason  to  think  it  pathological.    If  looked  for  it  will  be  found  very  frequently. 

Fig.  78.  Suggestion  in  an  X-ray  of  four  phalanges  in  the  little  toe  of  a 
young  person.  There  is  a  fracture  of  the  three  inner  metacarpals,  but  no  sign 
of  injury  to  the  fifth.  Of  course,  as  is  shown  in  the  text,  the  suggestion  is  a 
false  one. 

Fig.   79.   Ditto.     In  this  foot  there  is  no  suspicion  of  injury. 


PLATE  XXXVI. 


Fig.  76. 


Fig.  77. 


Fig.  78. 


Fig.  79. 


INDEX 


Astragalus,  p.  14,  15. 

post.  ext.  tubercle,  p.  is,  Fig.  43. 
post.  int.  tubercle,  p.  15,  16,  Fig.  39. 
trochlear  process,  p.  17,  Fig.  40. 
variations  of  shape,  p.  i&,  Figs.  41,  42,  43. 

Calcaneum,  p.  14,  17,  Figs.  36,  44,  45,  46,  47- 

peroneal  spine  of,  p.  14,  17,  Figs.  44,  45.  4S. 

secundarium,  p.  14,  Figs.  50,  51, -64,  70. 

synchondrosis  with  scaphoid,  see  Scaphoid. 

variations  of  shape,  p.  18,  Figs.  46,  47. 
Capitatum  proprium,  p.  1,8. 

secundarium,  p.  2,  8. 
Carpus,  bones  of,  p.  1. 

plan  of,  p.  1. 
Centrale,  p.  1,  5,  Figs.  7,  11,  12. 
Cuboid,  p.  14,  20. 

secundarium,  p.  14,  19,  20,  Figs.  59,  65. 
Cuneiform  (of  foot),  external,  p.  14,  20. 
internal,  p.  14,  19,  Figs.  61,  62. 
middle,  p.  14. 

(of  hand),  p.  6. 

Development  of  hands  and  feet,  p.  vii. 

Epilunatum,  p.  1,  3,  5,  Figs.  14,  15,  16,  17. 
Epipyramis,  p.  1,4,  6. 
Epitrapezium,  p.  1,  7. 
Epitrapezoid,  p.  1. 

Fusion:    astragalus  with  calcaneum,  p.  22. 
astragalus  with  scaphoid,  p.  22. 
cuboid  with  4th  and  5th  metatarsals,  p.  24. 
cuneiform    (of    hand)    with   semilunar,    p.    12,    Figs. 
28,  29. 
with  pisiform,  p.  12. 
(of   foot),    external    c.    with    middle    c,    p.    23. 
external    c.    with    3rd    metatarsal,    p.    23, 
Fig.  73. 
general,  of  carpus,  p.  13. 

2nd  metacarpal  with  trapezoid,  p.  13,  Fig.  31. 
3rd  metacarpal  with  trapezoid,  p.  13. 
3rd  metacarpal  with  os  magnum,  p.  13 
4th  metacarpal  with  5th,  p.   13,  Figs.  32,  33. 
os  magnuTi  with  trapezoid,  p.   13. 

with  unciform,  p.  13. 
phalanges,    4th   and    5th   toes,   p.  24,    Figs.   30,    77. 
trapezoid  with  scaphoid,  p.  13. 

Gruber's  ossicle,  p.  2,  8. 

Hamular  process,  see  Os  hamuli. 
Hypolunatum,  p.  1,  5,  6. 

Intercuneiform,  p.   14,  ig.  Figs.  63,  64. 
Intermetatarseum.  p.   14,   20,  Figs.  69,   70,   71,   72. 

Magnum,  see  Os  magnum. 

Metacarpals,  p.  9. 

Metacarpal,  proximal  epiphysis  in  2nd,  p.  9,  Fig.  30. 

styloid  process  of  3rd,  see  Styloid. 
Metastyloid,  p.  1,  10. 
Metatarsals,  p.  21. 
Metatarsal  1st  with  facet  for  2nd,  p.  21. 

5th  tuberosity  of,  p.  21,  Fig.  74. 


Os  calcis,  see  Calcaneum. 

hamuli,  p.  2,  8,  Figs.  22,  23. 

magnum,  p.  1,  8. 

sustentaculi,  p.  14,  17. 

unci,  p.  20. 
Ossification  of  bones  of  wrist  and  ankle,  p.  vii. 

Parastyloid,  p.  1,  9. 
Paratrapezium,  p.  1,  7. 
Peroneal  spine,  see  Calcaneum. 
Peroneum,  p.  14,  20,  Figs.  66,  67,  68. 
Pfitzner,  plan  of  hand  and  foot,  p.  ix,  1. 
Phalanges  (of  hand),  p.  10. 
(of  foot),  p.  21. 

see  under  Fusion. 

ossification  of  p.  of  little  toe,  p.  24. 
deceptive  appearance  in  X-ray  of  p.  of  little 
toe,  p.  25,  Figs.  78,  79. 
Pisiform,  p.  1,6. 

secundarium,  p.  1,6,  Figs.  18,  19. 
Praetrapezium,  p.  1,  7,  Fig.  20. 

Radiale  externum,  p.  1,  5,  Fig.  13. 

Scaphoid  (of  hand),  p.  1,3,  Figs.  6,  7,  10. 

divided,  p.  3,  4,  Figs.  2,  3,  4,  5,  8,  9. 
(of  foot),  p.  14,  18,  Figs.  59,  60. 
relations  with  cuboid,  p.  23. 
with  calcaneum,  p.  23. 
synchondrosis  with  cuboid,  p.  23,  Fig.  65. 

with  calcaneum,  p.  23,  Figs.  35,  36,  48,  49. 
trochlear  process  of,  p.  19. 
tuberosity  of,  p.  18,  Figs.  53,  60. 
Semilunar,  p.  5,  Fig.  16. 

divided  (?),  p.  5,  Fig.  15. 
Sesamoid  bones,  p.  viii. 

of  peroneus  longus,  see  Peroneum. 
of  tibialis  posticus,  see  Tibiale  externum. 
Sesamoids  (of  hand),  p.  11. 
(of  foot),  p.  22. 
of  thumb,  subdivided,  p.  n. 
of  great  toe,  subdivided,  p.  22,  Fig.  76. 
Styloid,  p.  2,  9,  Figs.  24,  25,  26,  27. 
Subcapitatum,  p.  2,  8,  Fig.  21. 


Tarsus,  bones  of,  p.  14. 

Thilenius,  p.  x. 

Tibiale  externum,  p.   14. 

60,  62,  70. 
Trapezium,  p.  1.  7. 

secundarium.  p.  1,  7. 
Trapezoid,  p.  1 ,  7. 

secundarium 
Triangulare,  p 


18,  Figs.  44,  52,  53,  54,  55,  56, 


9- 

Fig. 


Trigonum,  p.  14.  15.  Figs.  34,  35,  36,  37,  3? 

Ulnare  externum,  p.  1,6.  Fig.  17. 
Unciform,  p.  1,8,  Fig.  23. 
process,  see  Os  hamuli. 

Vesalianum  (of  hand),  p.  2.  10. 

(of  foot),  p.  14,  21,  Figs.  74,  75- 


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